Global Health: A Seminal Moment?

By Sudeep Chand

The time has arrived. The world's leading killers are finally getting attention on the global stage. In September 2011, the United Nations (UN) General Assembly will take on immense challenges such as heart disease and cancer.

These non-communicable diseases (NCDs) as they are known, now account for two-thirds of all deaths and half of global disability. And it won't stop here; deaths from NCDs are expected to rise by fifteen percent in the next ten years. So is this summit a seminal moment for prosperity and well-being?

While crises of finance, food and fuel have attacked the face of global prosperity, something else has been gnawing away on the inside. Slowly but surely, families have spent more on health, parents have missed work and businesses have found their productivity curtailed. Governments in rich countries have failed to curb the rise of health care costs. Emerging economies have spent more and more to avoid catastrophic payments that push people into poverty and slow economic growth. Meanwhile low-income countries increasingly face a double burden: high rates of infectious disease alongside NCDs. Increases in population size and age mean that eighty percent of deaths from NCDs now occur in low- and middle-income countries.

Interest in NCDs and their effect on societies has now reached unprecedented levels. The World Economic Forum now places NCDs high on its list of global financial risks. Governments are responding with high-profile reforms and initiatives. And civil society has responded in kind with the formation of an NCD Alliance consisting of 800 organisations across 170 countries.

The response has been driven by success stories in a number of regions with acknowledgement that a large proportion of these diseases are amenable to prevention and treatment. There are also opportunities to do this at lower costs, in settings away from expensive health facilities. Estimates state that up to thirty million lives could be saved over the next ten years. So are we about to see a transformation in the global response similar to that observed after the 2001 UN Summit on HIV/AIDS?

A number of political, strategic and technical challenges face the UN Summit. Early drafts of the summit documents have been criticised for being too focused on treatment. A prevention approach is vital and cost-effective. However, key interventions in tobacco, physical activity, diet and alcohol - the main opportunities for prevention of heart attacks, strokes, diabetes, cancer and chronic respiratory diseases - often conflict with other interests. For example, commercial incentives for tobacco production and consumption remain strong, despite evidence of economic disincentives for households and workforce productivity.

Another challenge arises from those diseases and determinants omitted from the list. The UN Summit is quite rightly focused on four key disease groups as a starting point. However, considerable burdens from mental health issues or risks from environmental degradation continue unaddressed. Previous investments in maternal and child health and unfinished business in infectious disease control also remain priorities in weak health systems. Fortunately, addressing NCDs helps reduce the burden of infectious disease. However, integrating NCDs into policy and management of these systems will take time.

Identifying the institutional tasks required to tackle issues as diverse as taxation, marketing, and health informatics will not be substantively addressed in one UN meeting. The World Health Organization will have a strong role to play, but its traditional strength has not been in catalysing policy changes in other sectors.

And in an age of crises in food, fuel and finance, finding a proposed nine billion dollars of funds for a new development goal will need to be a shared responsibility amongst governments and the private sector, whether rich or poor. However, there are good reasons to invest. Many effective interventions have a net economic benefit, costing far less than the full costs of treatment of illness, and in some cases generate about a three dollar return per one dollar invested. In addition, some drugs to prevent heart disease and stroke are increasingly affordable. Achievement of feasible reductions in risk, such as a two percent reduction in NCD death rates per year, has been estimated to increase economic growth by one percent per year after a decade.

An initial focus on tobacco control is perhaps prudent, given that 167 countries have pledged to implement strategies to reduce tobacco use in the context of a binding legal framework. So far, only ten percent of countries have acted on their commitments since the treaty took effect in 2005, despite a rising toll of 15,000 tobacco-related deaths each day across the globe.

What happens if we fail? It will cost us. Recent estimates place the global economic cost of NCDs between one to two trillion dollars. For every ten percent rise in mortality from NCDs, economic growth is estimated to reduce by 0.5 percent of GDP per year. By 2030, some regions will have experienced a fifty percent rise in deaths from NCDs. The cost of health care will also rise, as high as 25 percent of GDP in high-income countries. Development will stagnate as families are pushed into poverty through unemployment and the cost of social care.

Classically as countries develop, infectious deaths fall and NCD deaths rise. As the saying goes, you've got to die from something. However, rich countries have managed to get infectious diseases largely under control, with slow declines in disability from NCDs. In contrast, today's low- and middle-income countries will face stubbornly high burdens from NCDs due to the pace of this transition. Their populations are growing quickly, yet ageing with increased exposure to NCD risk factors and ongoing burdens from infectious disease. Societies and businesses will struggle as millions of people of working age no longer take part in the growth of economies.

The summit, like good medicine, will be pragmatic in that it will treat what it can treat. It might provide a political platform for a step-change in how we address health issues. At the heart of a coherent strategy should be a multi-level approach to addressing core determinants of disease, and strengthening health systems through primary care. A much stronger focus on local capacity, strategy and participation is what will turn the high-level discussions into meaningful outcomes.

In some ways, addressing HIV/AIDS was easier. Although far from achieved, the timescale on returns on investment were short. Governments were concerned with the implications for security, and civil society was mobilised behind a moral imperative. Chronic diseases are not so privileged. Their rise is associated with a much broader set of globalised policies and processes. NCDs are a test case of our collective ability to address complex global problems.

(Sudeep Chand is a Consultant Research Fellow at the Centre for Global Health Security, Chatham House.)

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