Closing the NCD Divide: A Matter of Equity and Social Justice

Both young and old suffer from NCDs in developing countries. The farther down on the socioeconomic scale one goes, however, the higher the impact on younger populations.
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The right to health of the majority of the world's inhabitants is severely hampered due to vast inequalities in access to care and many of the social rights that determine their health. These inequalities are not just a matter of health, but issues of social justice and human rights.

Non-communicable diseases (NCDs) kill four times the number of people in low- and middle-income countries (LMICs) that they do in high-income countries. Diseases traditionally associated with affluence -- such as cancer, cardiovascular disease and diabetes -- today plague and kill many more people who are poor, marginalized and unable to change their behaviors or environment. The increasing concentration of risk, preventable disability and mortality, stigma and pain and suffering among the poor fuels an unacceptable divide that must be remedied.

Both young and old suffer from NCDs in developing countries. The farther down on the socioeconomic scale one goes, however, the higher the impact on younger populations. It comes as no surprise that 29 percent of people who die from NCDs in developing countries are under the age of 60, compared to only 13 percent in high-income countries.

Although the majority of NCD mortality, morbidity and associated disability in children are largely preventable, many of our youngest -- the most exposed and at the same time promising future of our societies -- suffer and die from these diseases because of lack of diagnosis or access to treatment. Indeed, the cancer divide for children is the most dramatic: while 90 percent of Canadian children diagnosed with leukemia can hope for survival, the figure is the inverse -- only 10 percent -- in the poorest 25 countries.

In addition to a lack of access to health care, these children are often exposed to targeted advertising by food, beverage, tobacco and alcohol companies, or are left unprotected by the environmental hazards of poverty. Their exposure to risk -- for many diseases -- often begins well before birth with a lack of access to prenatal care, poor maternal nutrition and environmental and living conditions associated with poverty. Before they are even born, children are already at risk for NCDs.

The majority, though not all, of the most exposed and vulnerable populations live in LMICs and lack the opportunity and the ability to make healthy lifestyle choices. For the majority of people worldwide who suffer and die from diseases like cardiovascular disease, cancer and diabetes, the freedom to choose a healthier life was never part of the equation. To begin with, inadequate knowledge of exposure to risk eliminates any possibility of making informed choices or undertaking healthy behavior. Furthermore, much exposure to risk is beyond the control of individuals, especially where health policies and laws to protect them are inadequate or lacking. Nor can these individuals readily access proven early detection interventions.

The notion that NCDs are primarily the result of behavior that can be changed by individuals is an erroneous yet widespread misperception that perpetuates the health divide between rich and poor. Advocates need to reframe the NCD debate into an equity imperative and a key lever for economic, social and human development -- as has been done for some of the most polemic issues over time, from child labor to improving access to curative treatment and prevention for HIV/AIDS.

Evidence -- including economics -- is key. For example, the cost of inaction to prevent and provide care for treatable cancers costs the world hundreds of millions of dollars every year in lost productivity and costly end-of-life treatment. This type of evidence, in the hands of committed individuals, fighting for a cause about which they believe passionately, can change global, regional, national and local priorities.

To be successful we need to accept that the majority of people who suffer from NCDs have little choice when it comes to determining their health outcomes. The argument should not be about who is to blame -- this only reduces our space of action to an endless debate about prevention versus treatment. Rather than pigeonholing global and national policies against NCDs into the all-or-nothing debate of focusing exclusively on behavioral change, our actions must be broad and respond to the basic right of all individuals everywhere to have the capabilities to live a healthy life.

Placing the responsibility -- causal and curative -- for the NCD pandemic on the shoulders of the individuals who suffer unfair exposure to risk and disease is not the way to move forward and reduce avoidable deaths. By casting aside this misperception, NCDs will cease to be erroneously equated with personal health choices and become a larger human rights concern and a cause for global action.


Felicia Marie Knaul is associate professor at Harvard Medical School and director of the Harvard Global Equity Initiative, where she serves as co-director of the Global Task Force on Expanded Access to CancerCare and Control in Developing Countries. Benn Grover is a health communication specialist who manages the Policy for the National Forum for Heart Disease and Stroke Prevention.

This is one in a series of articles being published to mark the first anniversary of the 2011 United Nations High-Level Meeting on Non-Communicable Diseases on Sept. 19. The series is coordinated by the non-profit organization Arogya World in partnership with the Young Professionals Chronic Disease Network and will be housed at

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