501007
2013
PED0010.1177/1757975913501007CommentaryD. V. McQueen
Commentary NCDs, health promotion and public health David V. McQueen1
Abstract: Though not necessarily using the same terminology historically, people concerned with the public’s health have long been addressing the social context of non-communicable diseases (NCDs) and the actions of promoting health. This commentary places the current interest in NCDs within that history and discusses the challenges that continue to face institutions in dealing with NCDs. It makes a particular plea for the role of health promotion as the area of public health that takes actions to address the global burden of NCDs. Without a health promotion focus, we will just continue to describe the NCD burden rather than reduce it. (Global Health Promotion, 2013; 20 Supp. 4: 90–92). Keywords: chronic disease, health promotion, social context, disease burden, non-governmental organizations (NGOs)
Commentary Public health has always been concerned with population health concerns regardless of their etiological origins. This was particularly true in what Rosen aptly called the ‘industrialism and the sanitary movement’ from 1830 to 1875 (1). This was the period of the politicization of public health by such champions as Virchow. After that time, 20th century public health was focused largely on infectious diseases. This was partly as a result of the rise of a bacteriological theory of disease etiology, but can also be viewed as an inheritance from the European colonialism concern with hygiene and tropical medicine. From time to time, particularly from the mid-century onwards, there was also a modest interest in community and social medicine. Towards the end of the 20th century and in recent decades there has been increasing interest in non-infectious etiologies and chronic diseases in public health. This is manifested in the creation at the US Centers for Disease Control (CDC) in 1989 of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) and in 1992, the National Center for Injury Prevention and Control (2). More recently the term ‘non-communicable diseases’ has
become the acceptable term for the chronic disease area and simply referred to as NCDs, or sometimes NCDs and Injury (4). It is a conscious, albeit clumsy, choice, but one used internationally and championed by the World Health Organization (WHO) (3). While the NCD terminology rests uncomfortably with some, it has gained significant recognition through recent efforts by the WHO to engage the United Nations General Assembly to address NCDs in 2011 (5). Without doubt, NCDs deserve a major place in the public health world primarily because, as has been often reiterated, the consequences of NCDs are a major source of global deaths, suffering and economic challenges. Nonetheless, most public health researchers and practitioners know that the terminology is imperfect, and that work on NCDs includes many areas of public health work including mental illnesses, injury, and environmental challenges. From a general public health perspective NCDs, whether seen broadly as in the work of the WHO Commission on the Social Determinants of Health (6) or narrowly as in the limited approach of the Rio Declaration on the Social Determinants of Health (7), represent a particularly critical area for current public health action. This is particularly true because
1. Emory University, Rollins SPH, Atlanta, GA, USA. Correspondence to: David McQueen, Global Consultant, 2418 Midvale Ct, Tucker, GA, 30084 USA. Email: [email protected]
Global Health Promotion 1757-9759; Vol 20 Supp. 4: 90–92; 501007 Copyright © The Author(s) 2013, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913501007 http://ghp.sagepub.com Downloaded from ped.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
D. V. McQueen
of the emerging and forecasted burden NCDs place on low and middle-income countries (8). Despite the well-recognized burden of NCDs, the institutions, international, national and local, of public health have been slow to acknowledge two critical challenges related to NCDs. The first relates to capacity; the second relates to ideology. With regard to capacity, it is a well-recognized fact that in terms of resource commitments, public health institutions do not distribute these in relationship to the burden of NCDs. Across the globe, in institution after institution, the budgetary commitments to work on NCDs are proportionally small when compared with the allocations to communicable diseases. More critically, the number of positioned public health researchers and practitioners devoted to NCDs is not in proportion to the demand implied by the burden of NCDs and the opportunities to prevent and control them. While NCDs are a particularly pressing problem for low and middle-income countries where the public health infrastructure is often very weak, it is also characteristic of the many economically developed countries. This is a problem that will be very difficult to solve in a period where economies are challenged and growth of public health resources is often not seen as a priority. It could be asserted that an equitable redistribution of the current resources devoted to public health that adequately addressed both NCDs and infectious diseases to reflect the real burdens would leave public health damaged, particularly if there are no additional resources added. Thus the argument needs to be made that, independent of the infrastructure of public health institutions, more general funds may be the only practical and sufficient solution to address the needs of public health. Public health institutions and nongovernmental organizations (NGOs) will have to address this challenge urgently. The capacity issue will not disappear any time in the near future. The ideological challenge is equally fraught with difficulties. In essence, the traditional structure of public health institutions favors the biomedical over the social in its approach to public health and NCDs in particular. This despite the recent efforts to champion the role of social determinants in health and the recognition of the so-called ‘causes of the causes’ in disease etiology in such critical undertakings as the WHO Commission on the Social Determinants of Health. Certainly the Commission pointed out
91
clearly, and with a huge body of evidence, that many of the causes of morbidity and mortality in populations rested on a foundation of poverty, inequity, social injustice and poor health policy. This fact was not unknown prior to the comprehensive work of the Commission. It was the common understanding of those working in social epidemiology and the sociology of medicine since the latter half of the 20th century (9). What the Commission added was the firm recognition by the premier international health organization of the operation of a causal chain between social factors such as poverty, inequity, social justice, etc., leading to behavioral causes leading to unfortunate health outcomes, particularly in the chronic diseases. Furthermore, this line of causation held true regardless of a country’s level of economic development. There are many implications of this work. Most obvious is that many of the so-called causes cited by the Commission represent areas of work that lie outside of the training of many who research and practice public health. The fields of causal interest imply the requisite background in the social and political sciences to effectively address these fundamental causes. The growing field of social epidemiology is an effort within the current public health sphere to address these fundamental causes (10). Nevertheless, social epidemiology is bounded by its own biomedical theoretical base. The area of public health that has a salient role in dealing with these challenges is health promotion. However, health promotion as an area has its own burdens. Like the NCD area it lacks resources globally; it has a decidedly undeveloped global capacity and infrastructure. It is widely accepted that the NCD area is underrepresented in the public health infrastructure of most low and middleincome countries (11); by comparison, health promotion has even less a part of such infrastructures. Yet it is the area of public health that is most concerned with addressing broad health issues and focusing public health toward the social context of health. It is the spiritual home for those sociologists, anthropologists, political and social scientists who wish to not only prevent disease but to promote health. Particularly in the area of NCDs where many of the causes and solutions lie outside the area of clinical medicine, health promotion with its emphasis on social action would seem to be the logical partner to the disease-oriented specialists. In IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
Downloaded from ped.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
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addition, the ideology of health promotion is driven by the values of equity, social justice, and a concern with health as a human right within the guidelines laid out by the United Nations and enshrined in the WHO constitution. Health promotion does not seek to just describe the social determinants of health; it wishes to take action to change those determinants with the end goal of improving health. In sum, institutions, governmental and nongovernmental, have clear roles to play in addressing the burden of NCDs across the globe. A health promotion NGO such as the IUHPE has a special role to ensure that the field of public health addresses the NCD challenges. As an NGO it has the ability to advocate for the resources and capacities needed to address NCDs. It has a dedicated global membership of public health researchers and practitioners who are concerned that the future infrastructure for public health is commensurate with the health needs of populations affected by the NCDs. Conflict of interest The author declares that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Rosen G. A History of Public Health. New York: MD Publications, Inc.; 1958. 2. Sleet DA, Baldwin G, Marr A, Spivak H, Patterson S, Morrison C, et al. History of Injury and Violence as public health problems and emergence of the National Center for Injury Prevention and Control at CDC. J Safety Res. 2012; 43: 233–247.
3. World Health Organization. WHO Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. World Health Assembly document A61/8. Geneva, Switzerland: WHO; 2008. h t t p : / / w w w. w h o . i n t / n m h / A c t i o n p l a n - P C NCD-2008.pdf (accessed 10 August, 2013). 4. McQueen DV, McKenna MT, Sleet DA. Chronic Diseases and Injury. In: Merson MH, Black RE, Mills AJ, editors. International Public Health: Diseases, Programs, Systems, and Politics. Gaithersburg, Maryland: Aspen Publishers; 2001, p. 293–330. 5. General Assembly of the United Nations. High-level meeting on non-communicable diseases, September, 2011. http://www.un.org/en/ga/president/65/issues/ ncdiseases.shtml (accessed 10 August, 2013). 6. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. http://www.who.int/ social_determinants/thecommission/en/ (accessed 10 August, 2013). 7. WHO. Rio Political Declaration on the Social Determinants of Health. Rio di Janeiro, Brazil: WHO; 21 October 2011. http://www.who.int/sdhconference/ declaration/Rio_political_declaration.pdf (accessed 10 August, 2013). 8. Ebrahim S, Smeeth L. Non-communicable diseases in low and middle-income countries: a priority or a distraction? Int J Epidemiol. October 2005; 34(5): 961–966. 9. McQueen DV, Siegrist J. Sociocultural Factors in the etiology of chronic disease. Soc Sci Med. 1982; 16(4):353–367. 10. Krieger N. Epidemiology and the People’s Health: Theory and Context. Oxford, UK: Oxford University Press; 2011. 11. The World Bank Human Development Network. The growing danger of non-communicable diseases: acting now to reverse course. The World Bank; September 2011. http://siteresources.worldbank.org/ H E A LT H N U T R I T I O N A N D P O P U L AT I O N / R e s o u r c e s / P e e r- R e v i e w e d - P u b l i c a t i o n s / WBDeepeningCrisis.pdf (accessed 10 August, 2013).
IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
Downloaded from ped.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
2013
PED0010.1177/1757975913501007CommentaryD. V. McQueen
Commentary NCDs, health promotion and public health David V. McQueen1
Abstract: Though not necessarily using the same terminology historically, people concerned with the public’s health have long been addressing the social context of non-communicable diseases (NCDs) and the actions of promoting health. This commentary places the current interest in NCDs within that history and discusses the challenges that continue to face institutions in dealing with NCDs. It makes a particular plea for the role of health promotion as the area of public health that takes actions to address the global burden of NCDs. Without a health promotion focus, we will just continue to describe the NCD burden rather than reduce it. (Global Health Promotion, 2013; 20 Supp. 4: 90–92). Keywords: chronic disease, health promotion, social context, disease burden, non-governmental organizations (NGOs)
Commentary Public health has always been concerned with population health concerns regardless of their etiological origins. This was particularly true in what Rosen aptly called the ‘industrialism and the sanitary movement’ from 1830 to 1875 (1). This was the period of the politicization of public health by such champions as Virchow. After that time, 20th century public health was focused largely on infectious diseases. This was partly as a result of the rise of a bacteriological theory of disease etiology, but can also be viewed as an inheritance from the European colonialism concern with hygiene and tropical medicine. From time to time, particularly from the mid-century onwards, there was also a modest interest in community and social medicine. Towards the end of the 20th century and in recent decades there has been increasing interest in non-infectious etiologies and chronic diseases in public health. This is manifested in the creation at the US Centers for Disease Control (CDC) in 1989 of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) and in 1992, the National Center for Injury Prevention and Control (2). More recently the term ‘non-communicable diseases’ has
become the acceptable term for the chronic disease area and simply referred to as NCDs, or sometimes NCDs and Injury (4). It is a conscious, albeit clumsy, choice, but one used internationally and championed by the World Health Organization (WHO) (3). While the NCD terminology rests uncomfortably with some, it has gained significant recognition through recent efforts by the WHO to engage the United Nations General Assembly to address NCDs in 2011 (5). Without doubt, NCDs deserve a major place in the public health world primarily because, as has been often reiterated, the consequences of NCDs are a major source of global deaths, suffering and economic challenges. Nonetheless, most public health researchers and practitioners know that the terminology is imperfect, and that work on NCDs includes many areas of public health work including mental illnesses, injury, and environmental challenges. From a general public health perspective NCDs, whether seen broadly as in the work of the WHO Commission on the Social Determinants of Health (6) or narrowly as in the limited approach of the Rio Declaration on the Social Determinants of Health (7), represent a particularly critical area for current public health action. This is particularly true because
1. Emory University, Rollins SPH, Atlanta, GA, USA. Correspondence to: David McQueen, Global Consultant, 2418 Midvale Ct, Tucker, GA, 30084 USA. Email: [email protected]
Global Health Promotion 1757-9759; Vol 20 Supp. 4: 90–92; 501007 Copyright © The Author(s) 2013, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913501007 http://ghp.sagepub.com Downloaded from ped.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
D. V. McQueen
of the emerging and forecasted burden NCDs place on low and middle-income countries (8). Despite the well-recognized burden of NCDs, the institutions, international, national and local, of public health have been slow to acknowledge two critical challenges related to NCDs. The first relates to capacity; the second relates to ideology. With regard to capacity, it is a well-recognized fact that in terms of resource commitments, public health institutions do not distribute these in relationship to the burden of NCDs. Across the globe, in institution after institution, the budgetary commitments to work on NCDs are proportionally small when compared with the allocations to communicable diseases. More critically, the number of positioned public health researchers and practitioners devoted to NCDs is not in proportion to the demand implied by the burden of NCDs and the opportunities to prevent and control them. While NCDs are a particularly pressing problem for low and middle-income countries where the public health infrastructure is often very weak, it is also characteristic of the many economically developed countries. This is a problem that will be very difficult to solve in a period where economies are challenged and growth of public health resources is often not seen as a priority. It could be asserted that an equitable redistribution of the current resources devoted to public health that adequately addressed both NCDs and infectious diseases to reflect the real burdens would leave public health damaged, particularly if there are no additional resources added. Thus the argument needs to be made that, independent of the infrastructure of public health institutions, more general funds may be the only practical and sufficient solution to address the needs of public health. Public health institutions and nongovernmental organizations (NGOs) will have to address this challenge urgently. The capacity issue will not disappear any time in the near future. The ideological challenge is equally fraught with difficulties. In essence, the traditional structure of public health institutions favors the biomedical over the social in its approach to public health and NCDs in particular. This despite the recent efforts to champion the role of social determinants in health and the recognition of the so-called ‘causes of the causes’ in disease etiology in such critical undertakings as the WHO Commission on the Social Determinants of Health. Certainly the Commission pointed out
91
clearly, and with a huge body of evidence, that many of the causes of morbidity and mortality in populations rested on a foundation of poverty, inequity, social injustice and poor health policy. This fact was not unknown prior to the comprehensive work of the Commission. It was the common understanding of those working in social epidemiology and the sociology of medicine since the latter half of the 20th century (9). What the Commission added was the firm recognition by the premier international health organization of the operation of a causal chain between social factors such as poverty, inequity, social justice, etc., leading to behavioral causes leading to unfortunate health outcomes, particularly in the chronic diseases. Furthermore, this line of causation held true regardless of a country’s level of economic development. There are many implications of this work. Most obvious is that many of the so-called causes cited by the Commission represent areas of work that lie outside of the training of many who research and practice public health. The fields of causal interest imply the requisite background in the social and political sciences to effectively address these fundamental causes. The growing field of social epidemiology is an effort within the current public health sphere to address these fundamental causes (10). Nevertheless, social epidemiology is bounded by its own biomedical theoretical base. The area of public health that has a salient role in dealing with these challenges is health promotion. However, health promotion as an area has its own burdens. Like the NCD area it lacks resources globally; it has a decidedly undeveloped global capacity and infrastructure. It is widely accepted that the NCD area is underrepresented in the public health infrastructure of most low and middleincome countries (11); by comparison, health promotion has even less a part of such infrastructures. Yet it is the area of public health that is most concerned with addressing broad health issues and focusing public health toward the social context of health. It is the spiritual home for those sociologists, anthropologists, political and social scientists who wish to not only prevent disease but to promote health. Particularly in the area of NCDs where many of the causes and solutions lie outside the area of clinical medicine, health promotion with its emphasis on social action would seem to be the logical partner to the disease-oriented specialists. In IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
Downloaded from ped.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
92
Commentary
addition, the ideology of health promotion is driven by the values of equity, social justice, and a concern with health as a human right within the guidelines laid out by the United Nations and enshrined in the WHO constitution. Health promotion does not seek to just describe the social determinants of health; it wishes to take action to change those determinants with the end goal of improving health. In sum, institutions, governmental and nongovernmental, have clear roles to play in addressing the burden of NCDs across the globe. A health promotion NGO such as the IUHPE has a special role to ensure that the field of public health addresses the NCD challenges. As an NGO it has the ability to advocate for the resources and capacities needed to address NCDs. It has a dedicated global membership of public health researchers and practitioners who are concerned that the future infrastructure for public health is commensurate with the health needs of populations affected by the NCDs. Conflict of interest The author declares that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Rosen G. A History of Public Health. New York: MD Publications, Inc.; 1958. 2. Sleet DA, Baldwin G, Marr A, Spivak H, Patterson S, Morrison C, et al. History of Injury and Violence as public health problems and emergence of the National Center for Injury Prevention and Control at CDC. J Safety Res. 2012; 43: 233–247.
3. World Health Organization. WHO Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. World Health Assembly document A61/8. Geneva, Switzerland: WHO; 2008. h t t p : / / w w w. w h o . i n t / n m h / A c t i o n p l a n - P C NCD-2008.pdf (accessed 10 August, 2013). 4. McQueen DV, McKenna MT, Sleet DA. Chronic Diseases and Injury. In: Merson MH, Black RE, Mills AJ, editors. International Public Health: Diseases, Programs, Systems, and Politics. Gaithersburg, Maryland: Aspen Publishers; 2001, p. 293–330. 5. General Assembly of the United Nations. High-level meeting on non-communicable diseases, September, 2011. http://www.un.org/en/ga/president/65/issues/ ncdiseases.shtml (accessed 10 August, 2013). 6. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. http://www.who.int/ social_determinants/thecommission/en/ (accessed 10 August, 2013). 7. WHO. Rio Political Declaration on the Social Determinants of Health. Rio di Janeiro, Brazil: WHO; 21 October 2011. http://www.who.int/sdhconference/ declaration/Rio_political_declaration.pdf (accessed 10 August, 2013). 8. Ebrahim S, Smeeth L. Non-communicable diseases in low and middle-income countries: a priority or a distraction? Int J Epidemiol. October 2005; 34(5): 961–966. 9. McQueen DV, Siegrist J. Sociocultural Factors in the etiology of chronic disease. Soc Sci Med. 1982; 16(4):353–367. 10. Krieger N. Epidemiology and the People’s Health: Theory and Context. Oxford, UK: Oxford University Press; 2011. 11. The World Bank Human Development Network. The growing danger of non-communicable diseases: acting now to reverse course. The World Bank; September 2011. http://siteresources.worldbank.org/ H E A LT H N U T R I T I O N A N D P O P U L AT I O N / R e s o u r c e s / P e e r- R e v i e w e d - P u b l i c a t i o n s / WBDeepeningCrisis.pdf (accessed 10 August, 2013).
IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
Downloaded from ped.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
