Non-Communicable Diseases (NCDs): The Costs Of Omission From The MDGs Results In A September UN Summit

Over a decade later, as the obesity and tobacco epidemics loom and the burden of chronic disease continues to rise, the UN will hold a high-level summit on disease in two weeks. This time, it will finally focus on the prevention and control of non-communicable illnesses ...
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Written in collaboration with Katherine Warren and Laura Macherelli

Eleven years ago, leaders from 189 countries ratified the United Nations Millennium Declaration, a global commitment to reduce poverty, alleviate hunger and eradicate disease. Specifically targeted to the developing world, the eight Millennium Development Goals (MDGs) created an ambitious blueprint for global action to meet these core objectives by 2015. While three of the MDGs relate specifically to reducing child mortality, improving maternal health and eradicating infectious illnesses, the drafters and signatories of the Millennium Development Goals omitted the #1 killer of people worldwide: non-communicable diseases (NCDs).

Over a decade later, as the obesity and tobacco epidemics loom and the burden of chronic disease continues to rise, the UN will hold a high-level summit on disease in two weeks. This time, it will finally focus on the prevention and control of non-communicable illnesses, with a specific emphasis on the four most prevalent of these conditions: cancer, cardiovascular disease, diabetes and chronic respiratory disease. All four share many common risk factors including tobacco and alcohol use, unhealthy diets, obesity, physical inactivity and environmental carcinogens. The World Health Organization (WHO) estimates that there are more than one billion tobacco users globally, 80 percent of whom live in low- or middle-income countries, and 6 million people die every year from tobacco-related illnesses worldwide. Additionally, more than 1.46 billion adults are overweight and 502 million are obese.

In 2008, 48 percent of NCD deaths were linked to cardiovascular illness (17 million deaths), with cancers representing 21 percent (7.6 million deaths)), respiratory diseases representing 4.2 million deaths and diabetes 1.3 million deaths worldwide. A recent report found that nearly 10 percent of the world's adults have diabetes and the prevalence of this disease is rising rapidly. As a result of this rise in health damaging behaviors and resulting chronic conditions, researchers predict rapidly escalating medical costs and rates of physical disability ahead globally in this century.

In 2000, at the signing of the U.N. Millennium Declaration, the chronic disease epidemic went largely unnoticed by MDG signatories because of a few costly misconceptions. The first assumption was that non-communicable diseases were "maladies of affluence," affecting only the developed world. Quite the contrary, nearly 80 percent of non-communicable disease deaths--29 million annually--occur in low- and middle-income countries, with 29 percent of these fatalities occurring before the age of 60. In fact, more than 80 percent of cardiovascular and diabetes deaths, more than 67 percent of cancer deaths and nearly 90 percent of deaths from chronic obstructive pulmonary disease, occur in low- and middle-income countries. Furthermore, the average age of death for people from heart disease is at least 10 years younger in developing countries as compared to developed countries, robbing nations of citizens during their most productive years.

While the health impact of a mosquito bite carrying malaria parasites manifests rapidly as an infectious illness in most people, the health damaging effects of environmental, social, cultural and political factors in the development and distribution of non-communicable diseases are not always as evident. Though the onset of infectious illness is often acute and in many cases life-threatening, in the short term, the gradual onset of many NCDs is less apparent and immediately newsworthy.

However, the distinction between communicable (infectious) and non-communicable illnesses (chronic) is not always that clear. NCDs can be caused by infectious agents, such as H. pylori bacteria's link to stomach cancer and the human papillomavirus (HPV) association with cervical and oral cancers. In fact, it is estimated that as many as one in five cancers may be linked to infectious illness. Additionally, NCDs are also communicable illnesses through people's social networks that can spread health-damaging behaviors such as smoking, unhealthy eating and substance use. The bottom line, however, is that chronic diseases have a significant impact on every nation's health, economy and national security. With more than half of the world's 6.6 billion people living in cities with exposure to a myriad of health-damaging factors and an increasing incidence of age-related NCDs worldwide, Secretary General Ban Ki-Moon has called the chronic disease pandemic "a public health emergency in slow motion."

Moreover, while NCDs account for 60 percent of the global burden of disease in the developing world, only 3 percent of foreign aid and philanthropic spending is directed towards these illnesses. In terms of disease burden, donors spent about $0.78/DALY (disability-adjusted life year) attributable to NCDs in developing countries in 2007, as compared to $23.9/DALY attributable to HIV, TB and malaria. As death and disability from chronic disease, and its burden in terms of lost productivity and economic costs to businesses and to countries increase globally, increased resources and funding must be focused on fighting NCDs.

How has the chronic disease pandemic happened? In part, the globalization of Western lifestyles -- including the rapid proliferation and availability of fast food -- has contributed to the rising rates of obesity, heart disease and diabetes globally. In 1994, when Kuwait's first McDonald's opened, 15,000 customers formed a seven-mile line at the drive through. Globally, there are more than 32,000 McDonald's in 117 countries serving more than 64 million people daily. In 2006, the global fast food market grew by 4.8 percent, reaching $102.4 billion annually. This dramatically expanded access to and marketing of inexpensive fast food, combined with other factors, including more sedentary lifestyles, has helped fuel the obesity epidemic worldwide.

Not only are people in the world's poorest countries developing chronic diseases at a faster rate than high-income countries, they are also dying of them at earlier ages and in larger numbers. A key difference between the impact of chronic disease in rich and poor countries is that wealthy countries have more of the resources needed to treat chronic diseases. According to The Economist, five times as many people die from heart disease in Brazil as they do in Britain, though Brazil is not five times as populous.

According to the World Health Organization, deaths from NCDs are expected to rise at least 15 percent over the next 10 years worldwide, with Africa projected to see the highest relative increase of more than 20 percent. In the developing world, a dearth of prevention, screening and treatment resources is leading to increased rates of chronic illness. President Obasanjo of Nigeria stressed the urgency of the current situation, stating, "We cannot afford to say 'we must tackle the other diseases first- --HIV/AIDS, malaria, tuberculosis -- then we will deal with chronic disease.' If we wait even 10 years we will find the problem is even larger and more expensive to address."

NCDs affect global economic and social development. The World Economic Forum identified this set of diseases as the second most severe threat to the global economy, after wealth inequality between the rich and the poor, with the most severe impact in developing countries. According to economists, between 2006 and 2015, the predicted lost output of countries as a result of NCDs will be $13.8 billion in China and $16.7 billion in India alone. Obesity, the most recent risk factorfor chronic diseases to emerge globally over the past four decades, has yet to be reversed in any population by medical measures alone. In many countries, monitoring systems of population weight and nutrition as well as government responses to increasingly obesogenic environments are absent. Furthermore, without treatment and care, chronic diseases are much more debilitating for people in low-income and middle-income countries. Many people are forced to quit their jobs, thereby losing economic stability, and family members -- typically women -- must drop out of school or stop working to care for their sick relatives. By addressing the behavioral, environmental and structural factors that contribute to the development of NCDs, by implementing prevention strategies and by providing treatment, nations will strengthen their economies as well as the quality of life for their citizens.

The upcoming high-level UN Summit this month will raise awareness, evaluate priorities, mobilize the international community and galvanize government action to combat the burden of NCDs. The summit will address: 1) incidence and impact, 2) national capacity policy, 3) prevention and control and 4) international cooperation and coordination. The summit will ask for commitments from heads of state and their governments to provide resources and leadership for the development and implementation of strategies to address chronic diseases, including improving diagnosis and treatment, strengthening health systems so that they can accomodate the dual burden of infectious and chronic diseases, and investing in research, as well as monitoring and evaluation systems for NCDs globally. The recommendations from the UN Summit on NCDS will be important for everyone from the most savvy of patients in the U.S. to the most vulnerable populations in the developing world.

As we approach the expiration date for the MDGs in 2015, the omission of chronic disease from these targets has underscored the reality that nations must come together to address these illnesses globally. With this realization, several outcomes will be critical for the UN Summit to be successful. Countries, both developed and developing, will need to pledge specific funding for health systems strengthening and reform. Institutions that are addressing health-related MDGs like the GAVI Alliance, the Global Fund to Fight AIDS, TB and Malaria and the Gates Foundation can serve as models for the types of multilateral initiatives needed to combat NCDs.

Innovation and integration are required to ensure that synergies can be harvested across diseases by building infrastructure to address both infectious and chronic illnesses. With an aging population, many infectious diseases such as AIDS, and chronic illnesses like diabetes, are co-occurring. Best practices on prevention must be shared across countries in order to stop the chronic disease epidemic. In this regard, the importance of targeting women and girls is essential. As the NCD Alliance stressed in an urgent letter to UN Secretary-General last week, United Nations member states must set an overarching objective and timeline (as was done for the MDG's) to reduce preventable deaths from NCDs by 25 percent by 2025, as well as develop other clear, evidence-based targets and indicators for measuring progress globally. Importantly, member countries must also establish a strategy to address the NCD's of mental and neurological disorders, such as depression, schizophrenia and Alzheimer's disease, that affect hundreds of millions of people worldwide and that have been omitted as a focus of this UN Summit.

As in the fight against infectious diseases, the effort to combat and prevent chronic diseases will require a toolbox of public health and medical interventions: education, training, communications campaigns and medical services. Many cost-effective interventions currently exist to prevent and control NCDs worldwide. Global initiatives such as the WHO Framework Convention on Tobacco Control, which has worked to promote smoking cessation, require warning labels on tobacco packages, ban tobacco advertising to young people, increase taxes on tobacco products and protect populations from exposure to second-hand smoke; the WHO Global Strategy on Diet, Physical Activity and Health; and numerous other initiatives must be broadly implemented to reduce the risk factors for NCDs. The focus on health-systems strengthening and country ownership in the Global Health Initiative of the U.S. Government, should also add an emphasis on NCDs to its current focus of eliminating infectious illnesses, and reducing childhood and maternal mortality.

The triumph of public health accomplishments over the past century has led to a shift in the diseases that affect people worldwide. No longer does the majority of the world's population die of infectious disease, but instead of chronic illnesses -- many of which are linked to preventable, health-damaging, behavioral and environmental factors. The world is at a crossroads when it comes to the chronic disease epidemic and its enormous health and economic impacts. The United Nations and its member countries must take action at the summit in September and beyond, committing the political will and resources needed to combat non-communicable diseases globally. The result will be a healthier and more prosperous future for all.

Rear Admiral Susan Blumenthal, M.D. (ret.) is the Public Health Editor of the Huffington Post. She serves as Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, and Chair of the Global Health Program at the Meridian International Center. She served for more than 20 years in health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. Dr. Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. She was the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association. Admiral Blumenthal has been named by the National Library of Medicine, The New York Times and the Medical Herald as one of the most influential women in medicine and by GQ magazine and the Geoffrey Beene Foundation as a 2010 Rock Star of Science.

Katherine Warren, an undergraduate at Harvard University, served as a Health Policy Fellow at the Center for the Study of the Presidency and Congress in Washington D.C. She is the founding Co-Director of the Akili Initiative, an online student think tank for global health.

Laura Macherelli, a recent graduate of the University of Maryland, served as a Health Policy Intern at the Center for the Study of Presidency and Congress in Washington D.C.

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