Global response to non-communicable diseaseBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3823 (Published 30 June 2011) Cite this as: BMJ 2011;342:d3823
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The 2011 United Nations General Assembly on Non-Communicable Diseases: Where did all the (other) NCDs go?
While the efforts detailed in this Analysis article regarding the
agenda for the September UN meeting on non-communicable diseases are
laudable, further consideration is needed regarding the scope of
conditions for discussion at this critical meeting.
NCDs have traditionally encompassed a broad range of conditions
including mental, neurological and developmental disorders (1) but as
outlined, the UN meeting will focus entirely on four conditions: diabetes,
chronic obstructive pulmonary disease (COPD), cardiovascular disorders
(CVD) and the harmful use of alcohol. These conditions have apparently
been selected for their relative mortality burden and the reality that
they share several common risk factors which can therefore offer common
intervention targets. Risk factors to be targeted include tobacco use,
unhealthy diets (though not food insecurity), insufficient physical
activity, and the harmful use of alcohol. Although the justification for
selecting these four conditions seems rational, there are some critical
problems with the proposed NCD Program's approach that deserve discussion.
(1) Although the stated goal of the proposed NCD Program is to
address health problems in the poorer countries of the world, the
conditions selected are more problematic in high income, not low income
countries. The "epidemiological transition" is said to occur when the
infectious disease burden decreases and subsequently NCDs come to come to
be the dominant disease burden in the population. This transition isn't
occurring in most low income countries. Instead the poorest countries are
simply gaining additional NCD burden, usually among those in the upper
income strata of their population.(2) Under such circumstances one could
argue that the NCDs targeted should be those more common in low income
countries. But stroke, heart disease, diabetes, and COPD primarily affect
middle-aged and older adults while low income countries remain largely
populated by youth with more than 50% being less than 25 years old. From
the WHO's 2010 Report on the Global Status of NCDs(3), if one calculates
the burden of NCDs that would be addressed in the proposed agenda (i.e.
diabetes, COPD, CVD and the harmful use of alcohol) vs. the burden of NCDs
unaddressed using the proportion of age-adjusted NCD mortality, the
discrepancy between NCDs addressed by the proposed program and those
unaddressed, the "NCD Gap", differs substantially across income levels
with the upper middle income countries standing to benefit the most.
(2) The risk factors targeted are more prevalent in high and upper
middle income countries. To some extent, tobacco use, alcohol consumption,
and obesity are luxuries not yet affordable to the poorest in the world.
See Table 1 for the prevalence of these risk factors stratified by country
income level. Targeting risk factors where they are less prevalent is
going to be less efficient. Table 1 raises additional interesting
questions that won't be addressed by the proposed NCD program. For
example, given that other risk factors for hypertension (HTN) are
relatively low in low income countries (e.g. obesity, physical
inactivity), why are HTN rates relatively similar? Furthermore, risk
factors to be targeted are the risk factors for these conditions in higher
income countries. There are likely unique risk factors for cancer, type 2
diabetes, COPD and CVD in low income countries. These won't be addressed
in this "one-size-fits-all" approach. Furthermore, substantial evidence
exists to suggest that early deprivation and environmental exposures
impact the risk of later life health issues(4). This too will go
unexplored and unconsidered in the proposed NCD program.
(3) The metric being used to argue for addressing only this subset of
NCD "burden" is mortality. Since the 1990 Global Burden of Disease
Study(5) the metric used to consider the global disease burden has been
the disability adjusted life year (DALY). The DALY goes beyond the "body
count" and includes the important aspect of years of life "lost" to
disability. Why the move backward to a simple body count? Using the DALY,
the World Bank ranks epilepsy among the most cost effect conditions to
treat being both "very cost effective" and with a "quite low cost of
implementation".(1) Most of the 80 million people with epilepsy in the
world go untreated.(6) But the proposed NCD program won't address this
(4) The concept of "NCD" is rapidly being reduced to these four
conditions. This trend is especially troubling because the cited analyses
of the available data don't tell the whole story. Review the WHO's Global
Status Report on Non-Communicable Diseases(3) and all other NCDs are only
mentioned briefly in a four line footnote on page vii. Search the WHO or
UN websites--"NCD" now seems defined by and limited to the four selected
conditions. The NCD alliance doesn't include the World Federation of
Neurology, the Movement for Global Mental Health, the International League
against Epilepsy, or the Global Campaign against Headache, to name just a
few important yet disenfranchised groups. When did non-communicable
neurological, psychiatric, and developmental disorders stop being NCDs?
And what of all the other non-communicable diseases of public health
import that have somehow been excluded from an important global
initiative? Will other national and international bodies follow suit in
narrowing the boundaries of NCDs to the four conditions? The implications
for future health policy planning and research funding are staggering.
Richard Smith, past editor of the British Medical Journal, described
the NCD Alliance as "a quickly formed global body of organizations
concerned about NCDs" and on August 10th reported that invitations for the
September meeting had not yet been extended to selected delegates from non
-governmental organizations, academia and the private sector.(7)
Reportedly the meeting has gone "wobbly" partly because countries in
Africa don't want to be diverted from today's immediate health burden to
address the health problems they may have tomorrow. The devolving new
definition of "NCDs" is deeply concerning and if allowed to progress
without question may have negative consequences for health policy and
planning funding for many conditions previously considered "NCDs".
1. The World Bank. Disease Control Priorities in Developing Countries. New
York, NY: Oxford University Press & The World Bank; 2006.
2. Waters WF. Globalization and local response to epidemiological overlap
in 21st century Ecuador. Global Health. 2006;2:8.
3. World Health Organization. Global status report on noncommunicable
diseases. WHO; 2011.
4. Prentice AM, Moore SE. Early programming of adult diseases in resource
poor countries. Arch Dis Child. 2005 Apr;90(4):429-32.
5. Murray C, Lopez A. The global burden of disease: a comprehensive
assessment of mortality and disability from diseases, injuries, and risk
factors in 1990 and projected to 2020: Harvard School of Public Health;
6. Meyer AC, Dua T, Ma J, Saxena S, Birbeck G. Global disparities in the
epilepsy treatment gap: a systematic review. Bull World Health Organ.
7. Smith R. Richard Smith: UN Meeting on non-communicable diseases goes
wobbly. BMJ Group Blogs; 2011.
Table 1: The Prevalence by Income of Risk Factors Targeted in the Proposed NCD Program
Competing interests: I have received research funding from the US National Institute of Health, the Rockefeller Brothers Fund and the US Centers for Disease Control related to research on non-communicable diseases.
These authors call attention to the upcoming UN meeting on non-
communicable disease (NCD), and their identification of the outcomes they
would like to see as professionals in low and middle income countries is
compelling. I was glad to read their acknowledgement of first, the
challenge in finding a perfect definition of NCD, and second, the
conditions left out of WHO and UN definitions including those that are
psychiatric in nature. However, they go on to explain the exclusion of
mental health from the upcoming meeting's agenda. And in this I am left
feeling somewhat disheartened - by both the exclusion itself and the
authors' explanation. Notably, they state that "mental health" is left out
"because it has different causes and because of the need to prioritise"
(p.1). While I certainly understand and agree with the need to prioritise,
I am concerned with the idea that mental disorders have different causes
entirely. Are mental disorders not also understood and treated in terms of
their genetic, biological, and lifestyle roots? Are they not also deeply
influenced, even exacerbated, by the same social determinants that the
authors identify for non-communicable disease - globalisation,
Compounding my concern is the authors' confusion of language - a
pervasive problem in the everyday discourse surrounding this area of
health care. They speak of "mental health", referring to its global burden
and its different causes (3rd paragraph p.1). I assume their intention was
not to speak of the burden or causes of health, but rather of disease
and/or illness, perhaps with psychiatric disorders in mind. I point out
this slip in wording in order to highlight something that I suspect all of
us, at least in the English-speaking world, have been guilty of at one
time or another; that is, to say mental health when we mean mental
illness. When there is imprecise use of terms, there is confusion in
understanding. In coping with the confusion, mental health often gets
separated out from discussions of health and in turn, efforts toward
comprehensive health programming will always fall short.
For example, the authors' list of hoped-for outcomes from the UN
meeting reveals how quickly the 'mental health' dimensions of illness
experiences can disappear from health planning strategies. Specifically,
in the admittedly broad category of 'action on other risk factors',
psychosocial and emotional factors are absent. What about stress
management initiatives, supportive counselling, or community/peer support
groups in tandem with interventions focused on physical activity and
dietary change; strategies that have the potential to positively impact
mood, attitude, and resiliency?
Of course I look to hopeful initiatives like Grand Challenges for
Mental Health and the Movement for Global Mental Health in advancing
global issues of mental health care in terms of psychiatric disorders
specifically and mental health promotion broadly, but I also encourage us
all as health care providers to always be looking for creative ways of
thoughtfully and explicitly addressing the mental health dimensions of all
diseases - communicable and non-communicable alike. A robust global
response to health must be a response that considers mental health and
Competing interests: No competing interests