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Noncommunicable Diseases Shannon Marrero, BA1
Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG2
1 Brown’s Warren Alpert Medical School, Providence, Rhode Island 2 Department of Obstetrics and Gynecology, Brown University,
Providence, Rhode Island
Address for correspondence Shannon Marrero, BA, Brown’s Warren Alpert Medical School, 76 Locust St., Providence, RI 02906 (e-mail: [email protected]).
Abstract
Keywords
► noncommunicable diseases ► declaration ► global health
Noncommunicable diseases (NCDs), long considered diseases of little significance to global health, represent the greatest threat to economic development and human health. The main NCDs—diabetes, cancer, cardiovascular disease, and chronic respiratory disease—are the world’s number one killer and bear the greatest burden on the poor. On September 19–20, 2011, the United Nations General Assembly (UNGA) convened a high-level meeting (HLM) on the Prevention and Control of Non-Communicable Diseases. The only other HLM held on a health issue in the past had been in 2001 for HIV/AIDS and resulted in ambitious targets, global surveillance, and billions of dollars in aid. The 2011 HLM for NCDs did not measure up to the previous meeting in funding, targets, or advocacy but gave birth to a series of commitments in the form of a political declaration. In this article, we discuss the extent to which NCD is effecting the global population, what has and has not transpired since the 2011 HLM, and what lies ahead if we are to successfully tackle this growing burden of disease before it grows beyond our reach.
Noncommunicable Diseases: What Is in the Name? As defined by the World Health Organization (WHO), noncommunicable diseases (NCDs) comprised cardiovascular disease, chronic respiratory disease, diabetes, and cancers.1,2 Though other diseases fall under the umbrella term noncommunicable, the aforementioned four diseases are united by four shared modifiable risk factors—tobacco use, unhealthy diet, physical inactivity, and the harmful use of alcohol. Confining NCDs to four diseases with shared risk factors has allowed for the creation of shared targets, goals, and interventions. However, there are several problems with this acronym. First, defining diseases by what they are not, noncommunicable, does not speak to what they are. Second, by leaving out other diseases that are not communicable, such as autoimmune conditions, neurological and mental health disorders, the acronym is not inclusive. Third, by including diseases such as cervical cancer, which actually has a communicable etiology, the acronym has false implications. The
Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG
term NCDs is meant to capture the main causes of noncommunicable morbidity and mortality but is in no way inclusive or separate from its communicable counterparts, in definition or form.
An Unacknowledged Global Threat to Human Health and Development NCDs contributed to 34.5 million deaths in 2010, which is nearly two-thirds of all global deaths and more than all other causes of death combined.3 Around 9 million of these deaths were premature (occurring before the age of 60 years). The majority of premature deaths from NCDs (90%) occur in lowand middle-income countries (LMICs).4 Future projections suggest an even greater NCD burden. The WHO estimates that by 2020, NCD-attributable deaths will increase by 15% with the greatest increase in low-income regions; an increase of more than 20% is anticipated in Africa, South-East Asia, and the Eastern Mediterranean.4 Even though the majority of global deaths are from NCDs, they
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DOI http://dx.doi.org/ 10.1055/s-0034-1395277. ISSN 1526-8004.
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Semin Reprod Med 2015;33:35–40
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Marrero, Adashi
are largely underfunded (< 3% of global health aid), and left out of the Millennium Development Goals because they have been unrecognized and largely misunderstood.5,6 NCDs have been misconstrued as diseases of affluence mainly affecting high-income nations. The influence of socioeconomic circumstance on vulnerability to NCDs and the impact of health-damaging policies often go unacknowledged. NCDs are the insidious byproduct of depredated living and working conditions, unplanned urbanization, and globalized unhealthy lifestyles, which has had the greatest effect on the poorest nations and the poorest people within those nations. As both a cause and consequence of inequality, NCDs create a downward spiral; NCDs lead to unemployment which leads to poverty and greater risk for NCDs. In India, 1.4 to 2.0 million people spend more than 30% of their household income on cardiovascular disease alone, minimizing resources for economic stability and growth.7 NCDs are an impediment to economic development. As our population ages and LMICs industrialize, NCDs will grow, debilitating countries without the capacity to respond. The economic cost in LMICs from NCDs is estimated to exceed 7 trillion dollars between 2011 and 2025, which is approximately 4% of the gross domestic product (GDP) for all LMICs combined in 2010.8 The global economic burden from NCDs was approximately 6.3 trillion dollars in 2010, and is predicted to rise to $13 trillion in 2030 with a decrease in GDP of 0.5% for every 10% rise in NCDs,4 creating what Dr. Margaret Chan, director-general of WHO, NCDs, calls a “slow-motion disaster.”9
Global Recognition Leading to a High-Level Meeting NCDs were first discussed on the global level in 1996 when the WHO released The Global Burden of Disease.10 Then, in 2000 the WHO released The Global Strategy for the Prevention and Control of Non-Communicable Diseases, which united NCD by four common risk factors and allowed for them to release the 2008–2013 WHO Action Plan and Global Status Report which provided the tools and strategy for global action.11 Political will was the only missing ingredient until CARICOM, an organization uniting 15 Caribbean nations, stepped up to be the champion of such efforts and advocated for a United Nations General Assembly (UNGA) meeting. In the Caribbean, NCDs had risen to be the number one cause of premature mortality by 2007.12 Furthermore, the International Diabetes Federation, World Heart Federation, Union for Global Cancer Control, and International Union Against Tuberculosis and Lung Disease united to form the NCD Alliance, which proved to be a powerful advocating body. On May 20, 2010, the UNGA resolved to convene a UN General Assembly High-Level Meeting on NCDs in the coming year. The expectations were high considering the 2001 highlevel meeting (HLM) for HIV/AIDS, the only other previous HLM on a health issue gave birth to multiple national and international organizations, a multimillion dollar global fund, and a powerful social movement. However, the HLM for HIV/AIDS in 2001 proved to be very different from the Seminars in Reproductive Medicine
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2011 HLM for NCD for three reasons. First, NCDs did not have the same fear of contagion and moral underpinnings as HIV/AIDS.13 Second, the HLM for NCDs took place at the height of a global recession. Third, in reflecting on the first decade of the 21st century in global aid for HIV/AIDS, the importance of grass roots leadership in establishing sustainable programs proved to be of upmost importance. A transformation in global aid, from a hands-on approach to one that stressed country independence, took place between 2001 and 2011.14 As a result, the global response to NCD in 2011 did not match expectations or the scale of the NCD epidemic.
The Aftermath of the High-Level Meeting The meeting did result in a political declaration and widespread acknowledgment of the global impact of NCDs. The Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases was the main tangible deliverable of the HLM.15 Although nonbinding under international law, a political declaration has the potential to be a powerful tool in promoting global action. The declaration recognized the far-reaching health, social, economic, and developmental implications of NCDs; their underlying modifiable risk factors; and the overwhelming need to reduce NCD morbidity and mortality.15 The declaration stressed the importance of prevention and multisectoral collaboration. To establish health-promoting environments, the declaration placed special emphasis on the implementation of already established WHO instruments that could be used to prevent NCD such as the Framework Convention on Tobacco Control,16 the Global Strategy on Diet, Physical Activity and Health,17 and the Global Strategy to Reduce the Harmful Use of Alcohol.18 Additionally, the declaration called for the strengthening of country-level surveillance systems and the development of national diseasereducing targets and progress indicators.16 To accomplish these goals, the declaration called upon the WHO to develop a comprehensive global monitoring framework inclusive of progress indicators and voluntary global targets by the end of the subsequent calendar year and called upon the UN Secretary-General to submit options for action-promoting partnerships by 2012, report on the realization of commitments by 2013, and promulgate a comprehensive review of progress in the prevention and control of NCDs by 2014.16 The global attention from the 2011 HLM created a wave of attention directed toward NCDs in other declarations. One month after the HLM, NCD was named as one of the main developmental drivers of health inequities at the WHO World Conference on the Social Determinants of Health.19 The following year, at the UN Rio þ 20 Conference on Sustainable Development, NCDs were acknowledged as one of the major barriers to achieving social and health equity and a commitment to promoting affordable access to prevention, treatment, care, and support for NCDs was incorporated into the resulting declaration.20 Subsequently, on May 26, 2012, at the 65th World Health Assembly (WHA), delegates from 119 member states adopted the omnibus resolution on NCDs,
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which followed up on three of the major commitments from the 2011 Declaration: 1. Endorsing the Global Action Plan (GAP) 2013–2020 2. Adopting the Global Monitoring Framework (GMF), including 9 targets and 25 indicators 3. Agreeing to establish a global coordination mechanism (GCM) in addition to the UN Interagency Taskforce21 established in 2012 The GAP is meant to update the 2008–2013 Action Plan and provide a roadmap for the implementation of the political declaration from the 2011 HLM.22 The GMF includes 9 concrete targets for 2025 along with 25 outcome indicators and 9 progress indicators.23 The targets are focused on established risk factors, health systems response, and an outcome goal of a 25% relative reduction in mortality from NCDs by 2025 (see ►Table 1).24 The agreed upon 25 outcome indicators have been established to measure risk factors, disease burden, and national system responses. Examples include, but are not limited to the unconditional probability of dying between ages 30 and 70 from NCDs, the incidence of cancer by type of cancer per 100,000 population, age-standardized prevalence of hypertension (> 140/90 mm Hg) among persons age 18 or older, vaccination coverage against the hepatitis B virus as monitored by number of third doses of the Hep-B vaccine (HepB3) administered to infants, and access to palliative care as assessed by morphine-equivalent consumption of opioid analgesics per death from cancer. The availability of essential NCD medicines and basic technologies to treat major NCDs has also been targeted (80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities).24 The establishment of a GAP along with targets and indicators marked a huge success in
Marrero, Adashi
realizing the commitments of the political declaration, but without a global body to facilitate implementation, such a success is useless. In compliance with the declaration, a UN Interagency Task Force on the Prevention and Control of NCDs was established in 2012 to coordinate the activities of relevant UN agencies. In addition, a global coordinating mechanism is in the process of being established to address functional gaps that prove to be barriers to establishing coordinated efforts between nations.24 The specific components of the GCM have not been established, and the main function will be to enable the formation of shared strategies, aligned resources, and mutual encouragement. Following the approval of terms of reference at the 67th World Health Assembly in 2014, the GCM will be in place for the operational phase in 2015. On September 17, 2012, the secretary-general submitted a progress report on existing multisector partnerships, lessons learned from such partnerships, and key elements for successful approaches. He then proposed five options for global partnerships against NCDs.24 The first option was to align and enhance independent efforts in a similar manner to the Framework Convention on Tobacco Control. Like the declaration on NCD, the framework calls for a comprehensive, multisectoral approach to tobacco control that goes beyond health to encompass trade, tax, law enforcement, education, agriculture, and environment.25 Option two is to create a social movement similar to that of HIV/AIDS. Like HIV/AIDS, the reduction of NCDs is dependent on the government adopting favorable policies, the private sector developing innovative tools, and regulating bodies ensuring the price of necessary medicines is affordable.25 Option three involves the creation of a coordinated network that could encourage, monitor, and coordinate collaboration similar to the interagency task force on tobacco control.25 Option four consists of merging options
Table 1 Targets for global monitoring framework (WHO 2013) Risk factor targets
Health system response targets
Outcome targets
Halt the rise in diabetes and obesity
50% of eligible people receive drug therapy and counselling (including glycemic control) to prevent heart attacks and strokes
A 25% relative reduction in overall mortality from NCDs by 2025
10% relative reduction in physical inactivity
80% availability of affordable basic technologies and essential medicines, including generics required to treat major NCDs in both public and private facilities
At least 10% relative reduction in harmful use of alcohol 30% relative reduction in mean population intake of salt 30% relative reduction in prevalence of current tobacco use in persons aged 15 þ years 25% relative reduction in prevalence of raised blood pressure Abbreviation: NCDs, noncommunicable diseases. Seminars in Reproductive Medicine
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one, two, and three. Option five is the creation of a centralized vertical model like the Global Fund for HIV/AIDS. This is unlikely to succeed given the linkage of NCDs to primary care and the current political desire to move away from a fragmented health landscape. Additional recommendations in the secretary-general’s note include but are not limited to the appointment of national multisector agencies on NCD who are accountable for guiding national plans and reporting progress to government.25 By committing member states to the development of multisector national policies and plans on NCDs by the end of 2013, the political declaration placed a large amount of responsibility in the hands of individual countries.16 The National Capacity Assessment Survey on NCDs, conducted among member states in 2010 and again in 2013, shows that the majority (95%) of countries have a department or unit within the Ministry of Health responsible for NCD, but only half have operational policies or plans with a dedicated budget.26 Still, this is an improvement from the 32% of countries that had operational policies or plans with budgets in 2010. While the availability of NCD services—such as primary prevention, health promotion, and risk factor management—have seen modest rises, the number of countries conducting risk factor surveys more than doubled between 2010 and 2013, which is a remarkable improvement but suggests many countries are just beginning to gain a solid understanding of the extent to which NCDs are affecting their population.26
Ensuring Adherence to Commitments Promises are easy to make but difficult to carry out and monitor, especially without funding. The 2014 UN General Assembly Comprehensive Review will serve as the next checkpoint for progress on realizing the declaration commitments.26 The review has two main objectives. First, it will provide guidance on strengthening national capacities to develop targets and plans in line with the nine global targets and WHO Global NCD Action Plan 2013–2020. Second, the review will measure results, taking into account the 25 outcome indicators and the 9 progress indicators, and regional indicators.26 Moving forward, it is likely that some of the NCD risk factors will be incorporated into the post-2015 development agenda.27 The outcome document of the 2010 High-level Plenary Meeting of the General Assembly on the MDGs requested SecretaryGeneral Ban Ki-Moon provide recommendations on efforts to accelerate MDG progress in his annual report. Ban Ki-Moon established the UN system task team in September 2011 to support preparations for the post-2015 UN agenda. In the task team’s first report to the secretary-general, entitled Realizing the Future We Want for All, the team recognized that the MDGs did not adequately address several important issues, including the increase in NCDs.28 The report along with the sustainable development goals, established at the Rio þ 20 Conference on Sustainable Development, will be used during the Annual Ministerial Review by the Economic and Social Council to draw up a post-2015 development agenda.28 Seminars in Reproductive Medicine
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Potential Barriers to Action The majority of people in need of medicines for NCDs who live in LMICs do not have access.29 As a result, there is a disparity in morbidity and mortality from NCDs between high-income countries and LMICs. Patients with cancer in LMICs have half the survival rate of those in high-income countries.30,31 In the negotiation of the 2011 political declaration on NCDs, the United States of America and European Union disagreed with India, Brazil, Mexico, and other G77 members on whether or not the Trade Related Aspects of Intellectual Property Rights (TRIPS) agreement and Doha Declaration should be included in the declaration.32 The debate reflected the desire of EU and US representatives to limit the application of TRIPS to medicines for infectious disease.33 Ultimately, the political declaration included the application of TRIPS for NCD medicines but failed to mention the Doha Declaration. Without support for access to affordable medicines, it will be impossible to meet framework targets. Another potential barrier is the private sector to prioritizing financial gain over public health. The largest private companies have a long history of lobbying governments against passing policies that have proven to lower NCDs. The WHO outlined several interventions such as tobacco taxation, salt reduction in processed foods, and the prohibition of public smoking that require little funding, only government support. However, intense lobbying from the tobacco, alcohol, and packaged food companies has the potential to thwart government implementation. In the United States, PepsiCo spent more than $9 million in 2009 to lobby the US Congress.34,35 With such large forces operating in poor countries, it is difficult to compete. A third barrier to reducing NCDs is inequality. Without decreasing inequity, it will be impossible to significantly lower NCDs. The most disadvantaged carry the greatest NCD burden.4 If equity is not incorporated as a key indicator, we will see only a minor benefit from global action and the poorest people could be further marginalized.32 A reduction in the NCD burden and a reduction in health inequities are mutually reinforcing and interdependent.
An Integrated System Moving forward, without new streams of funding, our best option is to incorporate NCDs into infrastructure established over the past two decades. NCDs have the advantage of learning from previous mistakes and building off of already established clinics and public health programs across the world. Patients with HIV/AIDS are surviving longer but are more at risk for developing NCDs such as diabetes or cardiovascular disease.36 Thus, treatment for HIV/AIDS and NCDs both involve patient adherence to long-term treatment regimens, which makes incorporating simple NCD treatment and screenings into HIV/AIDS visits a natural fit. Currently, in many regions of the world, it is better to have HIV/AIDS than diabetes because access to antiretroviral medication is better than access to insulin.
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13 United Nations Security Council (UNSC). Resolution 1308 on HIV/
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NCDs continue to be the most unacknowledged threat to economic development and human health despite recent global attention. In the coming years, progress will be made only if access to medications is expanded, private interests are limited, global commitments are met, access to primary care and prevention are more universal, and extra support is given to LMICs to establish national efforts. While the challenges of addressing the growing burden of NCDs are great, doing nothing poses a threat to our very existence.
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commitments made in the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (informal note). Available at: http:// www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCwQFjAA&url=http%3A%2F%2Fwww.who.int%2Fnmh%2Fevents%2Fun_ncd_summit2011%2FWHO_NCDs_Outline_of_SG_report.pdf&ei=LmnXUvr5KIbqoASlmoGgDw&usg=AFQjCNFjvXvr583 o0OXVycAXJSZtYIocpw&bvm=bv.59568121,d.cGU. Accessed January 5, 2014
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Noncommunicable Diseases Shannon Marrero, BA1
Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG2
1 Brown’s Warren Alpert Medical School, Providence, Rhode Island 2 Department of Obstetrics and Gynecology, Brown University,
Providence, Rhode Island
Address for correspondence Shannon Marrero, BA, Brown’s Warren Alpert Medical School, 76 Locust St., Providence, RI 02906 (e-mail: [email protected]).
Abstract
Keywords
► noncommunicable diseases ► declaration ► global health
Noncommunicable diseases (NCDs), long considered diseases of little significance to global health, represent the greatest threat to economic development and human health. The main NCDs—diabetes, cancer, cardiovascular disease, and chronic respiratory disease—are the world’s number one killer and bear the greatest burden on the poor. On September 19–20, 2011, the United Nations General Assembly (UNGA) convened a high-level meeting (HLM) on the Prevention and Control of Non-Communicable Diseases. The only other HLM held on a health issue in the past had been in 2001 for HIV/AIDS and resulted in ambitious targets, global surveillance, and billions of dollars in aid. The 2011 HLM for NCDs did not measure up to the previous meeting in funding, targets, or advocacy but gave birth to a series of commitments in the form of a political declaration. In this article, we discuss the extent to which NCD is effecting the global population, what has and has not transpired since the 2011 HLM, and what lies ahead if we are to successfully tackle this growing burden of disease before it grows beyond our reach.
Noncommunicable Diseases: What Is in the Name? As defined by the World Health Organization (WHO), noncommunicable diseases (NCDs) comprised cardiovascular disease, chronic respiratory disease, diabetes, and cancers.1,2 Though other diseases fall under the umbrella term noncommunicable, the aforementioned four diseases are united by four shared modifiable risk factors—tobacco use, unhealthy diet, physical inactivity, and the harmful use of alcohol. Confining NCDs to four diseases with shared risk factors has allowed for the creation of shared targets, goals, and interventions. However, there are several problems with this acronym. First, defining diseases by what they are not, noncommunicable, does not speak to what they are. Second, by leaving out other diseases that are not communicable, such as autoimmune conditions, neurological and mental health disorders, the acronym is not inclusive. Third, by including diseases such as cervical cancer, which actually has a communicable etiology, the acronym has false implications. The
Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG
term NCDs is meant to capture the main causes of noncommunicable morbidity and mortality but is in no way inclusive or separate from its communicable counterparts, in definition or form.
An Unacknowledged Global Threat to Human Health and Development NCDs contributed to 34.5 million deaths in 2010, which is nearly two-thirds of all global deaths and more than all other causes of death combined.3 Around 9 million of these deaths were premature (occurring before the age of 60 years). The majority of premature deaths from NCDs (90%) occur in lowand middle-income countries (LMICs).4 Future projections suggest an even greater NCD burden. The WHO estimates that by 2020, NCD-attributable deaths will increase by 15% with the greatest increase in low-income regions; an increase of more than 20% is anticipated in Africa, South-East Asia, and the Eastern Mediterranean.4 Even though the majority of global deaths are from NCDs, they
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DOI http://dx.doi.org/ 10.1055/s-0034-1395277. ISSN 1526-8004.
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Semin Reprod Med 2015;33:35–40
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are largely underfunded (< 3% of global health aid), and left out of the Millennium Development Goals because they have been unrecognized and largely misunderstood.5,6 NCDs have been misconstrued as diseases of affluence mainly affecting high-income nations. The influence of socioeconomic circumstance on vulnerability to NCDs and the impact of health-damaging policies often go unacknowledged. NCDs are the insidious byproduct of depredated living and working conditions, unplanned urbanization, and globalized unhealthy lifestyles, which has had the greatest effect on the poorest nations and the poorest people within those nations. As both a cause and consequence of inequality, NCDs create a downward spiral; NCDs lead to unemployment which leads to poverty and greater risk for NCDs. In India, 1.4 to 2.0 million people spend more than 30% of their household income on cardiovascular disease alone, minimizing resources for economic stability and growth.7 NCDs are an impediment to economic development. As our population ages and LMICs industrialize, NCDs will grow, debilitating countries without the capacity to respond. The economic cost in LMICs from NCDs is estimated to exceed 7 trillion dollars between 2011 and 2025, which is approximately 4% of the gross domestic product (GDP) for all LMICs combined in 2010.8 The global economic burden from NCDs was approximately 6.3 trillion dollars in 2010, and is predicted to rise to $13 trillion in 2030 with a decrease in GDP of 0.5% for every 10% rise in NCDs,4 creating what Dr. Margaret Chan, director-general of WHO, NCDs, calls a “slow-motion disaster.”9
Global Recognition Leading to a High-Level Meeting NCDs were first discussed on the global level in 1996 when the WHO released The Global Burden of Disease.10 Then, in 2000 the WHO released The Global Strategy for the Prevention and Control of Non-Communicable Diseases, which united NCD by four common risk factors and allowed for them to release the 2008–2013 WHO Action Plan and Global Status Report which provided the tools and strategy for global action.11 Political will was the only missing ingredient until CARICOM, an organization uniting 15 Caribbean nations, stepped up to be the champion of such efforts and advocated for a United Nations General Assembly (UNGA) meeting. In the Caribbean, NCDs had risen to be the number one cause of premature mortality by 2007.12 Furthermore, the International Diabetes Federation, World Heart Federation, Union for Global Cancer Control, and International Union Against Tuberculosis and Lung Disease united to form the NCD Alliance, which proved to be a powerful advocating body. On May 20, 2010, the UNGA resolved to convene a UN General Assembly High-Level Meeting on NCDs in the coming year. The expectations were high considering the 2001 highlevel meeting (HLM) for HIV/AIDS, the only other previous HLM on a health issue gave birth to multiple national and international organizations, a multimillion dollar global fund, and a powerful social movement. However, the HLM for HIV/AIDS in 2001 proved to be very different from the Seminars in Reproductive Medicine
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2011 HLM for NCD for three reasons. First, NCDs did not have the same fear of contagion and moral underpinnings as HIV/AIDS.13 Second, the HLM for NCDs took place at the height of a global recession. Third, in reflecting on the first decade of the 21st century in global aid for HIV/AIDS, the importance of grass roots leadership in establishing sustainable programs proved to be of upmost importance. A transformation in global aid, from a hands-on approach to one that stressed country independence, took place between 2001 and 2011.14 As a result, the global response to NCD in 2011 did not match expectations or the scale of the NCD epidemic.
The Aftermath of the High-Level Meeting The meeting did result in a political declaration and widespread acknowledgment of the global impact of NCDs. The Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases was the main tangible deliverable of the HLM.15 Although nonbinding under international law, a political declaration has the potential to be a powerful tool in promoting global action. The declaration recognized the far-reaching health, social, economic, and developmental implications of NCDs; their underlying modifiable risk factors; and the overwhelming need to reduce NCD morbidity and mortality.15 The declaration stressed the importance of prevention and multisectoral collaboration. To establish health-promoting environments, the declaration placed special emphasis on the implementation of already established WHO instruments that could be used to prevent NCD such as the Framework Convention on Tobacco Control,16 the Global Strategy on Diet, Physical Activity and Health,17 and the Global Strategy to Reduce the Harmful Use of Alcohol.18 Additionally, the declaration called for the strengthening of country-level surveillance systems and the development of national diseasereducing targets and progress indicators.16 To accomplish these goals, the declaration called upon the WHO to develop a comprehensive global monitoring framework inclusive of progress indicators and voluntary global targets by the end of the subsequent calendar year and called upon the UN Secretary-General to submit options for action-promoting partnerships by 2012, report on the realization of commitments by 2013, and promulgate a comprehensive review of progress in the prevention and control of NCDs by 2014.16 The global attention from the 2011 HLM created a wave of attention directed toward NCDs in other declarations. One month after the HLM, NCD was named as one of the main developmental drivers of health inequities at the WHO World Conference on the Social Determinants of Health.19 The following year, at the UN Rio þ 20 Conference on Sustainable Development, NCDs were acknowledged as one of the major barriers to achieving social and health equity and a commitment to promoting affordable access to prevention, treatment, care, and support for NCDs was incorporated into the resulting declaration.20 Subsequently, on May 26, 2012, at the 65th World Health Assembly (WHA), delegates from 119 member states adopted the omnibus resolution on NCDs,
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which followed up on three of the major commitments from the 2011 Declaration: 1. Endorsing the Global Action Plan (GAP) 2013–2020 2. Adopting the Global Monitoring Framework (GMF), including 9 targets and 25 indicators 3. Agreeing to establish a global coordination mechanism (GCM) in addition to the UN Interagency Taskforce21 established in 2012 The GAP is meant to update the 2008–2013 Action Plan and provide a roadmap for the implementation of the political declaration from the 2011 HLM.22 The GMF includes 9 concrete targets for 2025 along with 25 outcome indicators and 9 progress indicators.23 The targets are focused on established risk factors, health systems response, and an outcome goal of a 25% relative reduction in mortality from NCDs by 2025 (see ►Table 1).24 The agreed upon 25 outcome indicators have been established to measure risk factors, disease burden, and national system responses. Examples include, but are not limited to the unconditional probability of dying between ages 30 and 70 from NCDs, the incidence of cancer by type of cancer per 100,000 population, age-standardized prevalence of hypertension (> 140/90 mm Hg) among persons age 18 or older, vaccination coverage against the hepatitis B virus as monitored by number of third doses of the Hep-B vaccine (HepB3) administered to infants, and access to palliative care as assessed by morphine-equivalent consumption of opioid analgesics per death from cancer. The availability of essential NCD medicines and basic technologies to treat major NCDs has also been targeted (80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities).24 The establishment of a GAP along with targets and indicators marked a huge success in
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realizing the commitments of the political declaration, but without a global body to facilitate implementation, such a success is useless. In compliance with the declaration, a UN Interagency Task Force on the Prevention and Control of NCDs was established in 2012 to coordinate the activities of relevant UN agencies. In addition, a global coordinating mechanism is in the process of being established to address functional gaps that prove to be barriers to establishing coordinated efforts between nations.24 The specific components of the GCM have not been established, and the main function will be to enable the formation of shared strategies, aligned resources, and mutual encouragement. Following the approval of terms of reference at the 67th World Health Assembly in 2014, the GCM will be in place for the operational phase in 2015. On September 17, 2012, the secretary-general submitted a progress report on existing multisector partnerships, lessons learned from such partnerships, and key elements for successful approaches. He then proposed five options for global partnerships against NCDs.24 The first option was to align and enhance independent efforts in a similar manner to the Framework Convention on Tobacco Control. Like the declaration on NCD, the framework calls for a comprehensive, multisectoral approach to tobacco control that goes beyond health to encompass trade, tax, law enforcement, education, agriculture, and environment.25 Option two is to create a social movement similar to that of HIV/AIDS. Like HIV/AIDS, the reduction of NCDs is dependent on the government adopting favorable policies, the private sector developing innovative tools, and regulating bodies ensuring the price of necessary medicines is affordable.25 Option three involves the creation of a coordinated network that could encourage, monitor, and coordinate collaboration similar to the interagency task force on tobacco control.25 Option four consists of merging options
Table 1 Targets for global monitoring framework (WHO 2013) Risk factor targets
Health system response targets
Outcome targets
Halt the rise in diabetes and obesity
50% of eligible people receive drug therapy and counselling (including glycemic control) to prevent heart attacks and strokes
A 25% relative reduction in overall mortality from NCDs by 2025
10% relative reduction in physical inactivity
80% availability of affordable basic technologies and essential medicines, including generics required to treat major NCDs in both public and private facilities
At least 10% relative reduction in harmful use of alcohol 30% relative reduction in mean population intake of salt 30% relative reduction in prevalence of current tobacco use in persons aged 15 þ years 25% relative reduction in prevalence of raised blood pressure Abbreviation: NCDs, noncommunicable diseases. Seminars in Reproductive Medicine
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one, two, and three. Option five is the creation of a centralized vertical model like the Global Fund for HIV/AIDS. This is unlikely to succeed given the linkage of NCDs to primary care and the current political desire to move away from a fragmented health landscape. Additional recommendations in the secretary-general’s note include but are not limited to the appointment of national multisector agencies on NCD who are accountable for guiding national plans and reporting progress to government.25 By committing member states to the development of multisector national policies and plans on NCDs by the end of 2013, the political declaration placed a large amount of responsibility in the hands of individual countries.16 The National Capacity Assessment Survey on NCDs, conducted among member states in 2010 and again in 2013, shows that the majority (95%) of countries have a department or unit within the Ministry of Health responsible for NCD, but only half have operational policies or plans with a dedicated budget.26 Still, this is an improvement from the 32% of countries that had operational policies or plans with budgets in 2010. While the availability of NCD services—such as primary prevention, health promotion, and risk factor management—have seen modest rises, the number of countries conducting risk factor surveys more than doubled between 2010 and 2013, which is a remarkable improvement but suggests many countries are just beginning to gain a solid understanding of the extent to which NCDs are affecting their population.26
Ensuring Adherence to Commitments Promises are easy to make but difficult to carry out and monitor, especially without funding. The 2014 UN General Assembly Comprehensive Review will serve as the next checkpoint for progress on realizing the declaration commitments.26 The review has two main objectives. First, it will provide guidance on strengthening national capacities to develop targets and plans in line with the nine global targets and WHO Global NCD Action Plan 2013–2020. Second, the review will measure results, taking into account the 25 outcome indicators and the 9 progress indicators, and regional indicators.26 Moving forward, it is likely that some of the NCD risk factors will be incorporated into the post-2015 development agenda.27 The outcome document of the 2010 High-level Plenary Meeting of the General Assembly on the MDGs requested SecretaryGeneral Ban Ki-Moon provide recommendations on efforts to accelerate MDG progress in his annual report. Ban Ki-Moon established the UN system task team in September 2011 to support preparations for the post-2015 UN agenda. In the task team’s first report to the secretary-general, entitled Realizing the Future We Want for All, the team recognized that the MDGs did not adequately address several important issues, including the increase in NCDs.28 The report along with the sustainable development goals, established at the Rio þ 20 Conference on Sustainable Development, will be used during the Annual Ministerial Review by the Economic and Social Council to draw up a post-2015 development agenda.28 Seminars in Reproductive Medicine
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Potential Barriers to Action The majority of people in need of medicines for NCDs who live in LMICs do not have access.29 As a result, there is a disparity in morbidity and mortality from NCDs between high-income countries and LMICs. Patients with cancer in LMICs have half the survival rate of those in high-income countries.30,31 In the negotiation of the 2011 political declaration on NCDs, the United States of America and European Union disagreed with India, Brazil, Mexico, and other G77 members on whether or not the Trade Related Aspects of Intellectual Property Rights (TRIPS) agreement and Doha Declaration should be included in the declaration.32 The debate reflected the desire of EU and US representatives to limit the application of TRIPS to medicines for infectious disease.33 Ultimately, the political declaration included the application of TRIPS for NCD medicines but failed to mention the Doha Declaration. Without support for access to affordable medicines, it will be impossible to meet framework targets. Another potential barrier is the private sector to prioritizing financial gain over public health. The largest private companies have a long history of lobbying governments against passing policies that have proven to lower NCDs. The WHO outlined several interventions such as tobacco taxation, salt reduction in processed foods, and the prohibition of public smoking that require little funding, only government support. However, intense lobbying from the tobacco, alcohol, and packaged food companies has the potential to thwart government implementation. In the United States, PepsiCo spent more than $9 million in 2009 to lobby the US Congress.34,35 With such large forces operating in poor countries, it is difficult to compete. A third barrier to reducing NCDs is inequality. Without decreasing inequity, it will be impossible to significantly lower NCDs. The most disadvantaged carry the greatest NCD burden.4 If equity is not incorporated as a key indicator, we will see only a minor benefit from global action and the poorest people could be further marginalized.32 A reduction in the NCD burden and a reduction in health inequities are mutually reinforcing and interdependent.
An Integrated System Moving forward, without new streams of funding, our best option is to incorporate NCDs into infrastructure established over the past two decades. NCDs have the advantage of learning from previous mistakes and building off of already established clinics and public health programs across the world. Patients with HIV/AIDS are surviving longer but are more at risk for developing NCDs such as diabetes or cardiovascular disease.36 Thus, treatment for HIV/AIDS and NCDs both involve patient adherence to long-term treatment regimens, which makes incorporating simple NCD treatment and screenings into HIV/AIDS visits a natural fit. Currently, in many regions of the world, it is better to have HIV/AIDS than diabetes because access to antiretroviral medication is better than access to insulin.
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13 United Nations Security Council (UNSC). Resolution 1308 on HIV/
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NCDs continue to be the most unacknowledged threat to economic development and human health despite recent global attention. In the coming years, progress will be made only if access to medications is expanded, private interests are limited, global commitments are met, access to primary care and prevention are more universal, and extra support is given to LMICs to establish national efforts. While the challenges of addressing the growing burden of NCDs are great, doing nothing poses a threat to our very existence.
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commitments made in the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (informal note). Available at: http:// www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCwQFjAA&url=http%3A%2F%2Fwww.who.int%2Fnmh%2Fevents%2Fun_ncd_summit2011%2FWHO_NCDs_Outline_of_SG_report.pdf&ei=LmnXUvr5KIbqoASlmoGgDw&usg=AFQjCNFjvXvr583 o0OXVycAXJSZtYIocpw&bvm=bv.59568121,d.cGU. Accessed January 5, 2014
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