Intended for healthcare professionals

Analysis

# Global response to non-communicable disease

BMJ 2011; 342 (Published 30 June 2011) Cite this as: BMJ 2011;342:d3823
1. UnitedHealth, National Heart, Lung, and Blood Institute Centers of Excellence
1. Correspondence to: R Smith, UnitedHealth Chronic Disease Initiative, London, UK richardswsmith{at}yahoo.co.uk
• Accepted 15 June 2011

The forthcoming UN meeting on non-communicable diseases is an important opportunity for promoting global action on conditions that have been neglected. A network of researchers from low and middle income countries describes what is needed

Despite causing 63% of global deaths, with 80% occurring in the developing world,1 non-communicable diseases did not feature in the millennium development goals and account for less than 3% of global health aid.2 The huge global burden from non-communicable diseases is expected to increase substantially over the next few years, and urgent action is needed (box 1).1 3 In September the United Nations will hold a high level summit on non-communicable diseases. The only previous UN meeting on health, in 2001, led to the Global Fund to Fight AIDs, Tuberculosis, and Malaria, which has saved millions of lives. We, a group of researchers mostly from low and middle income countries, describe how the UN meeting provides an opportunity to mount a major global response to non-communicable diseases, how its success can be made more likely, and what outcomes we would like to see.

#### Box 1: Burden of non-communicable disease13

• 36 million deaths a year, 63% of global deaths

• 80% of deaths from cardiovascular and diabetes and almost 90% of deaths from chronic obstructive pulmonary disease occur in low and middle income countries

• 29% of deaths from non-communicable diseases in low and middle income countries occur in people under 60 compared with 13% in high income countries

• Deaths are projected to increase by 15% between 2010 and 2020 with increases of 20% in Africa, the Middle East, and South East Asia

• Almost 6 million people a year die from tobacco use, 3.2 million from physical inactivity, 2.3 million from the harmful use of alcohol, 7.8 million from raised blood pressure, and 2.8 million from being overweight or obese

• The 12.7 million new cases of cancer in 2008 will increase to 21.4 million by 2030, with two thirds of cases being in low and middle income countries

• Non-communicable diseases accounted for five of the six top causes of economic loss in 2008: cancer $895bn (£550bn; €625bn), heart disease$752bn, stroke $298bn, diabetes$204bn, and chronic obstructive pulmonary disease \$203bn

• Non-communicable diseases are a major cause of families falling into poverty and block development

## Problems of definition

One reason for the inadequate response to non-communicable diseases is the problem of definition. Much time has been wasted trying unsuccessfully to find a perfect term. It is unsatisfactory to define anything by what it is not, and non-communicable diseases include not only the four conditions referred to by the World Health Organisation (WHO) and the UN—cardiovascular disease, diabetes, chronic obstructive pulmonary disease, and common cancers—but many neurological, rheumatological, and psychiatric conditions. Plus non-communicable disease means nothing to ordinary people. Nevertheless, it seems as if the term—or rather its acronym, NCD—is becoming the accepted description. The alternative term, chronic disease, is also unhelpful because many infectious diseases, not least AIDS and tuberculosis, are chronic.

The UN meeting will concentrate on cardiovascular disease, diabetes, chronic obstructive pulmonary disease, and some cancers because they account for so much mortality, morbidity, and cost and have similar causes—tobacco use, poor diet, physical inactivity, and the harmful use of alcohol. Behind these lie social determinants of globalisation, urbanisation, and poverty. Some have argued that mental health should be included in the meeting because of its huge global burden and close relation with the four cardinal conditions, but for now it has been excluded because it has different causes and because of the need to prioritise.

## Origins and processes of UN meeting

WHO produced its global strategy for the prevention and control of non-communicable diseases in 2000,4 but it was another eight years before it produced its action plan.5 During that time it has, however, produced the Framework Convention on Tobacco Control in 2003,6 the Global Strategy on Diet and Physical Activity in 2004,7 and the Global Strategy on the Harmful Use of Alcohol in 2008.8 But WHO has few staff working on non-communicable diseases and, until recently, little happened beyond the framework convention, the production of reports, and the raising of global consciousness among a small group of policy makers and scientists.

If the global pandemic of non-communicable diseases is to be given the attention it deserves then something more is needed. Many countries—particularly the Caribbean Community (CARICOM) countries—have recognised that effective action depends on much more than health ministries and so pushed for the UN high level meeting.

The meeting will last two days, be attended by heads of state and government, and adopt a “concise action-oriented outcome document.” The meeting will also be attended by civil society, the private sector, and academia. Jamaica and Luxembourg are charged with conducting consultations with member states and drafting an outcomes document to be agreed in the months leading up to the summit.

All the WHO regions have held meetings to prepare for the summit, and the first global ministerial conference on healthy lifestyles and non-communicable disease control was held in Moscow in April, producing the Moscow declaration.9 10 WHO has also published the Global Status Report on Noncommunicable Disease 2010,1 which gives detailed information on non-communicable diseases by country and is intended to provide a baseline against which to measure progress (or the lack of it).

## Can we emulate the success of the AIDS meeting?

Peter Piot, who was head of UNAIDS, has with other authors analysed the factors that made the United Nations 2001 meeting on HIV/AIDS so successful, and some of those factors do not exist for non-communicable diseases.11

Firstly, HIV/AIDS is a single disease that can be tackled with a few interventions—improved access to antiretroviral drugs plus expanded care and preventive services. Measurable results could be achieved quickly. Non-communicable diseases, in contrast, are many conditions that need multiple different interventions, many of them not available to health ministries and services. It is possible, however, to take actions against non-communicable diseases—such as raising the price of tobacco and alcohol and banning smoking in public places—that carry almost no financial cost and yet can be very effective.

Secondly, the time was ripe. There was a 15 year history of investment in HIV/AIDS with a sense of moral urgency, fear of contagion, and worries about threats to security. Non-communicable diseases have not had the same investment, and there isn’t the same level of global anxiety. Indeed, many donors—including the Gates Foundation and USAID—have explicitly excluded non-communicable diseases from their programmes, although the Gates Foundation has funded work on tobacco. Plus this is the “age of austerity,” when new funds will be hard to find.

Thirdly, those concerned about AIDS had strong leadership and a vocal, coherent social movement that included people living with HIV and high profile advocates. Those concerned about non-communicable diseases lack all these advantages, although the NCD Alliance—formed last year from the International Diabetes Federation, the World Heart Federation, the Union for International Cancer Control, and the International Union Against Tuberculosis and Lung Disease, and comprising some 900 national organisations—has made an impressive start in a short time.12

Fourthly, the AIDS community had specific “asks,” targets, and funding requests. Those concerned about non-communicable diseases are agreed that they do not want another Global Fund—partly because it’s highly unlikely that such a fund would be forthcoming but also because vertical programmes (those that concentrate on a single issue) may undermine the health systems that are essential for long term improvement in health. Some believe that it would be more sensible to concentrate on strengthening health systems so that they can deal with any health problem, but such a belief perhaps underestimates how much effective action depends on actors other than health services. Groups such as the NCD Alliance and the Lancet action group have published lists of outcomes they would like from the UN summit (boxes 2 and 3, table),12 13 and, although there is more agreement than disagreement, there is probably still a need to prioritise.

#### Box 2: Outcomes NCD Alliance would like from the UN high level meeting (selections from the 35 requests)12

• Include non-communicable diseases in the global development goals that succeed the millennium development goals in 2015

• Reduce death rates by at least 2% a year

##### Prevention (seven requests)
• Accelerate the effective implementation of the Framework Convention on Tobacco Control

• By 2013, develop and implement comprehensive strategies to decrease childhood obesity, and eliminate all forms of marketing for foods high in saturated fats, transfats, salt, and refined sugars by 2016

##### Diagnosis and treatments (three requests)
• Ensure universal access to affordable, high quality essential medicines and technologies, including radiotherapy and cancer medicines by 2020, antihypertensives and statins by 2015, insulin and other diabetes medicines by 2015, and asthma inhalers by 2012

##### Health systems (four requests)
• By 2016, 60% and by 2020 80% of countries to integrate health system management of non-communicable diseases

##### Resources (five requests)
• Allocate sufficient funds to UN and member states to support the implementation of the UN Summit outcomes document

##### Research (two requests)
• Encourage, increase, and accelerate research into causes and cures of non-communicable diseases

##### Human rights/vulnerability (three requests)
• Accelerate approaches to tackle the social determinants of non-communicable diseases

##### Monitoring/follow-up (two requests)
• Devote time at every UN General Assembly to review progress

#### Box 3: Recommendations from the Lancet NCD Action Group for the UN high level meeting on non-communicable diseases13

• Sustained and strong high level political support for a framework of specific commitments to tackle the crisis with the aim of reducing non-communicable disease death rates by 2% a year

##### Prevention
• Accelerate implementation of the WHO Framework Convention on Tobacco Control to achieve a world essentially free from tobacco by 2040, where less than 5% of people use tobacco

• Reduce daily salt intake to less than 5 g (2000 mg sodium) per person by 2025

• Align national policies on agriculture, trade, industry, and transport to promote improved diets, increase physical activity, and reduce harmful alcohol use

##### Treatment
• Deliver cost effective and affordable essential drugs and technologies for all priority disorders

• Strengthen health systems to provide patient centred care across different levels of the health system, starting with primary care

##### International cooperation
• Raise the priority of non-communicable diseases on global agendas, and increase funding for these diseases

• Promote synergies between programmes for non-communicable diseases and other global health priorities, including sustainability and mitigation of climate change

##### Monitoring, reporting, and accountability
• Identify ambitious targets and a transparent reporting system

• Assess progress on the priority actions and interventions

• Report regularly to the UN and other forums on progress on these national and international commitments

Lancet NCD Action Group’s five priority interventions for non-communicable disease with estimated costs in three countries13

View this table:

## Outcomes we would like to see

The UN meeting will mark the “end of the beginning not the beginning of the end,” and it’s surely right to see it as an important part of a process rather than end in itself. With that thought in mind, and emphasising again that we are mostly from developing countries, we would like to see seven outcomes from the meeting. These are close to the Lancet’s requests.

### Commitment to reducing burden

The UN should voice a strong commitment to reduce the burden of non-communicable diseases and call on all member states to make a similarly strong commitment and prepare and implement national plans for countering these diseases. Just as the Moscow Declaration did, the UN should emphasise the need for action by the “whole of government and whole of society,” and it should stress the importance of tackling non-communicable diseases for development. An important driver of the pandemic of non-communicable diseases is unfair international trade and subsidy. The UN should also appoint a special envoy for non-communicable diseases and review progress regularly.

### Create a global partnership

There should be a call for a “Stop NCD Partnership,” a body perhaps analogous to the Stop TB Partnership.14 This body should include global organisations like WHO and the World Bank, non-governmental organisations, patients and communities, academics, and the private sector. Such a partnership will acknowledge that effective action is beyond single actors. Good governance will be crucial. The body should produce and publish an agreed global strategy for countering non-communicable diseases with measurable targets, and every year publish an update on progress. Clearly, it will be essential to improve global surveillance and monitoring for the targets and updates to have any meaning.

### Action on tobacco

The third outcome we would like is rigorous implementation of the Framework Convention on Tobacco Control.6 There is strong and convincing evidence on how to reduce harm from tobacco, the framework is built on that evidence, and 172 countries are parties to it. Everybody who has proposed outcomes for the UN meeting agrees on this outcome, and most organisations list it as their first “ask.”

### Action on other risk factors

The UN should also call for action on the other risk factors—poor diet, physical inactivity, and the harmful use of alcohol. The WHO Global Status Report on Noncommunicable Disease 2010 included a list of 10 “best buys” on reducing the burden of non-communicable diseases, all of which are public health actions on risk factors, including tobacco, salt, alcohol, sugars, fats, and physical activity (box 4).1 The Lancet also includes sodium reduction, promotion of healthy diets and physical activity, and reduction of harmful alcohol consumption among its five priorities (table).13 This ask is much broader and more diffuse than our first three, and the evidence on how to achieve improvements in diet and physical activity is less convincing than that on tobacco, although the evidence on the effectiveness of raising the price of alcohol is strong. It is also an area where the private sector could have a role. Box 5 shows a draft of what some private companies are offering in support of the UN meeting through the Clinton Global Initiative.

#### Box 4: “Best buys” from WHO for reducing the burden of non-communicable diseases

• Protecting people from tobacco smoke and banning smoking in public places

• Warning about the dangers of tobacco use

• Raising taxes on tobacco

• Enforcing bans on alcohol advertising

• Raising taxes on alcohol

• Reduce salt intake and salt content of food

• Replacing transfats in food with polyunsaturated fat

• Promoting public awareness about diet and physical activity, including through mass media

#### Box 5: Actions offered in support of UN actions on non-communicable diseases from private companies associated with Clinton Global Initiative

We believe that stronger global private-public alliances are needed to complement government initiatives and extend their reach. In that spirit we undertake to implement specific actions within the following broad areas:

##### Healthy workforces and families
• Implement smoke-free workplaces and smoking cessation support within our companies and extend these across our supply chains

• Provide healthy foods and opportunities for physical activity within our workplaces

• Ensure that employees have access to effective age appropriate screening and referral for major non-communicable diseases

##### Healthy food and drink
• Globally implement WHO’s food and beverage marketing policies; and ensure that food and beverages are labelled in ways that help consumers make informed and healthy choices.

• Reduce sodium and saturated fat levels across all food and beverage products, while increasing the availability of fruits, vegetables, whole grains and pulses worldwide

• Eliminate full calorie sugar drinks from schools worldwide and ensure that alternatives meet internationally accepted nutrition norms for children.

• Shift agricultural incentives towards favouring dietary changes required to prevent non-communicable diseases and protect the environment

• Support efforts to expand access to essential diagnostics required for cardiovascular disease, diabetes, and certain cancers and related treatments in an affordable manner

• Improve adherence to long term therapy through collaboration with expanding IT platforms

• Develop new drug combination suited to low income settings and to countries where infectious diseases are common

• Healthy environments

• Work with city and town planners to increase activity as an easy daily option for communities where they live and recreate

• Invest in model community based activity programmes that link to environmental conservation and urban renewal

• Strong academic and research capacity

• Work together with major public and private funders to strengthen human and institutional capacity aimed at building the future cadre of non-communicable disease leaders

Access to technologies such as blood pressure machines and antihypertensive drugs is essential to combat non-communicable diseases. The Lancet has also called for access to essential drugs and technologies, and it puts an emphasis on a multidrug combination (polypill) for people identified as being at risk for cardiovascular disease together with risk assessment tools that do not depend on blood tests. Recent trials have shown that multidrug combinations will reduce blood pressure, serum lipids, platelet stickiness, and cardiovascular risk,15 16 but there has not yet been a trial of such a combination in primary prevention with cardiovascular events and mortality as end points. Treating those assessed to be at risk is probably the right emphasis; it is probably too controversial to call for a polypill for everybody based simply on age, even though age is a strong predictor of risk of cardiovascular disease.17 18 Drugs for diabetes, cancer, and asthma take a lower priority. Although agreeing on priorities may be difficult, a call for access to simple technologies is close to the familiar call for antiretroviral drugs and condoms for HIV/AIDS.

### Strengthened health systems

Effective reduction in the burden of non-communicable diseases will depend on strengthening the information supply, service delivery, workforce, and surveillance capabilities of health systems. Around a billion people in the world have no access to healthcare, and the World Health Report 2010 called for more commitment on universal health coverage.19 Development of primary care should be the priority, and existing health systems need to be reoriented to move from episodic, fragmented care to continuous, integrated care.

Improved health systems would also be beneficial for communicable disease, maternal and child health, and mental health. The difficulty is that it’s not easily achieved in a world short of funds and health workers.

### More research

The final outcome that we would welcome from the UN meeting is an emphasis on research, particularly implementation and translation research. The WHO Action Plan calls for more research, and WHO has just released a document on priorities in research to reduce the burden of non-communicable diseases, particularly in low and middle income countries. 20 Improved surveillance of non-communicable diseases and their risk factors will be particularly important. Research is also urgently needed into how to strengthen health systems. It should be uncontroversial for the UN meeting to call for more research, and funding bodies would surely pay attention. Indeed, several national funding bodies have already formed a Global Alliance on Chronic Disease, which is now calling for proposals. 21

## Realistic expectations

Sir George Alleyne, former director of the Pan-American Health Organisation and one of the main instigators of the UN meeting, has argued that there should be no more than four asks. He suggests action on risk factors, particularly tobacco and possibly salt, monitoring and surveillance, access to simple technologies like drugs for hypertension, and health system strengthening, concentrating on funding, human resources, and information. These four exist in almost everybody’s list of asks and if they became the priorities of the UN meeting they would surely provide a good outcome.

## Notes

Cite this as: BMJ 2011;342:d3823

## Footnotes

• Contributors and sources: The authors are principal investigators and other researchers in a network of centres of excellence in low and middle income countries conducting research into non-communicable diseases. These authors comprise Maria Teresa Cerqueira (Mexico), Alejandro Cravioto (Bangladesh), Nancy Dianis (US), Hassen Ghannem (Tunisia), Naomi Levitt (South Africa), Lijing L Yan (China), Sylvester Kimaiyo (Kenya), Tracey Koehlmoos (Bangladesh), Jaime Miranda (Peru), Louis Niessen (Bangladesh), Dorairaj Prabhakaran (India), Manuel Ramirez-Zea (Central America), Adolfo Rubinstein (Argentina), Yangfeng Wu (China), and Denis Xavier (India). Another author is Richard Smith, director of the UnitedHealth Chronic Disease Initiative. RS wrote the first draft. All of the authors discussed the draft at a meeting in Guatemala. RS then revised the paper. All of the authors have read the final version critically. The views expressed are those of the individuals, not their organisations or funders.

• Competing interests: All authors have completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; all of the authors are researchers and receive funds from the National Heart, Lung, and Blood Institute, the UnitedHealth Group, or both. We clearly have an interest in non-communicable diseases receiving more attention and more funds being available for research.

• Provenance and peer review: Not commissioned; externally peer reviewed.

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