Thomas J. Bollyky
Foreign Affairs, May/
When most people in developed countries think of the biggest health challenges confronting the developing world, they envision a small boy in a rural, dusty village beset by an exotic parasite or bacterial blight. But increasingly, that image is wrong. Instead, it is the working-age woman living in an urban slum, suffering from diabetes, cervical cancer, or stroke -- noncommunicable diseases (NCDs) that once confronted wealthy nations alone.
NCDs in developing countries are occurring more rapidly, arising in younger people, and leading to far worse health outcomes than ever seen in developed countries. This epidemic results from persistent poverty, unprecedented urbanization, and freer trade in emerging-market nations, which have not yet established the health and regulatory systems needed to treat and prevent NCDs. According to the
The international community has done little to help. Most donors remain focused on the battle against infectious diseases, reluctant to divert their funds. A recent
Collective action on NCDs need not wait for UN endorsement, economic recovery, or a reallocation of money away from campaigns against infectious diseases. The international community can make progress now by addressing those NCDs that are especially prevalent among poor people in developing countries and by helping their governments combat those diseases. For this effort to succeed,
The Disease Divide
The NCD problem in developing countries is far worse than it has ever been in the developed world. NCDs in emerging-market nations are arising in young working-age populations at higher rates and with more detrimental outcomes than in wealthy states. According to the
NCDs that are preventable or treatable in developed countries are often death sentences in the developing world. Whereas cervical cancer can largely be prevented in developed countries thanks to the human papillomavirus vaccine, in sub-Saharan Africa and
The rise of NCDs has devastating social and economic consequences for developing countries. The frequent onset of these diseases among younger populations consumes scarce health-care resources, saps labor from the work force and hinders economic development, and makes it harder for governments to address other threats, such as infectious diseases. On the household level, NCDs consume budgets and rob families of their primary wage earners. A recent report by
The reasons for the exploding NCD crisis in developing countries begin, paradoxically, with increased life expectancy. The greater availability of effective medical technologies, such as vaccines, and the improved diffusion of good public health practices, such as hand washing and breastfeeding, have sharply lowered child mortality across the globe. The vast majority of the world's newborns are now immunized against diseases such as measles, polio, and yellow fever, and the widespread use of oral rehydration salts has made cholera deaths increasingly rare. According to the
Extending lives is, of course, a good thing. But the problem is that although life expectancies for the poor have increased in low- and middle-income countries, they have done so without the gains in personal wealth and better health systems that accompanied the rise in longevity in most developed countries. With the significant exception of
The nearly nonexistent regulation of tobacco, alcohol, and processed food products in many developing countries compounds the challenges of rampant poverty and inadequate health care by increasing the likelihood that poor people will develop NCDs. These nations fear that increased taxes on unhealthy products will damage their economies and lead to public discontent. Regulators face strident opposition from tobacco, food, and beverage producers, which are sometimes partly or fully owned by the government in question. In many developing countries, patient-advocacy groups hardly exist. Civil litigation, which played a critical role in improving tobacco control and education in
Meanwhile, freer trade and the increased global integration of tobacco, food, and beverage markets are overwhelming the little public health infrastructure that does exist in many developing countries. With stagnating sales in high-income nations, multinational companies now target low- and middle-income countries, launching sophisticated advertising campaigns to drive growth. Tobacco companies, in particular, use billboards, cartoon characters, music sponsorships, and other methods now prohibited in most of the developed world to entice women, who used to be less likely to smoke than men. These tactics have raised tobacco sales across
Unprecedented rates of urbanization in developing countries have exacerbated these challenges. In 1950, over 70 percent of the world's population lived in towns and villages; by 2008, a majority had moved to cities. Most of this urbanization has occurred in emerging-market nations, where cities have little public health infrastructure. The result has been slums -- 90 percent of which are in developing countries and which house nearly one billion people. The inhabitants of these densely packed areas, faced with pollution outdoors and the burning of fuels indoors, are more susceptible to cardiovascular and respiratory diseases. Slum dwellers are more likely to buy tobacco products and cheap processed foods and less likely to have access to adequate nutrition or public health education.
The Right Prescription
Despite the enormity of the NCD epidemic devastating the poor in developing countries, it is possible to slow and reverse it. The measures necessary to prevent NCDs in healthy people are well known, and affordable medicines exist for improving care for those already living with these diseases. Treatments for NCDs, such as insulin and asthma inhalers, are no longer under patent and would do much to reduce avoidable disability and death if made more widely available.
The international community can help developing countries build the capacity necessary to implement these policies. To begin with, the WHO and its member countries should attempt to reach a firm consensus on the prevention and treatment strategies needed to address the NCDs particularly striking the poor in developing nations. Next, based on those strategies, they should design a practical package of programs that emerging-market countries can implement even in low-infrastructure settings. This might involve, for instance, determining the minimum level of taxes and the scope of marketing restrictions needed to diminish unhealthy alcohol consumption. Experienced health and tax officials from the developed world should then work with their counterparts in the developing world to build their capacity to carry out these protocols.
Modest levels of aid from philanthropic foundations, donor governments, and multilateral development banks would enable low-income countries to pilot and launch these efforts. Developed countries should establish a program to monitor these NCD control measures, publishing the results to hold governments accountable for their implementation.
The international community has long known of the NCD crisis plaguing the developing world. The WHO first called attention to the problem in 1996, when it issued a landmark report that contradicted long-standing views of NCDs as diseases of affluence, reporting that they would soon dwarf the burden of infectious diseases in developing countries and pose severe challenges to their health-care systems. Over the next decade, the WHO concluded an international treaty on tobacco control, produced numerous strategy papers on NCD prevention and treatment, and launched a department dedicated to addressing NCDs on a global level.
Yet despite these efforts, the WHO attracted little international support for action against NCDs. Global health donors and institutions remained preoccupied with containing infectious diseases and improving maternal and child health. According to a 2010 report by the
To place NCDs firmly on the international agenda, a group of concerned countries and nongovernmental organizations (NGOs) successfully lobbied to hold a high-level meeting on NCDs at the
Yet optimism faded before the meeting had even begun. NGOs fought over the lack of focus on other major NCDs, such as mental illnesses. The donors that have dominated the international responses to infectious diseases, such as the
The commitments that emerged from the meeting were largely rhetorical. The resulting political declaration recognized the "epidemic proportions" of NCDs and noted that countries can prevent them with cost-efficient public health measures, but it did not mandate specific methods nor even argue for their adoption. It endorsed private-sector partnerships and the sharing of technical assistance between developed and developing countries, but it failed to designate anyone to organize or fund such initiatives. The most concrete action mandated was to shift the responsibility for NCDs back to the WHO, charging it with generating voluntary disease- and risk-reduction targets, since nations could not agree on mandatory policies, and asking UN members to "consider" these targets in developing their national NCD plans. The WHO recently announced that it would probably not be able to get its 194 member countries to agree on these voluntary targets until at least
In the end, the UN meeting helped mobilize the NGO community and broaden public recognition of the human and economic toll of NCDs worldwide. Several governments, of their own volition, introduced new regulations on trans fats and dietary salt. Numerous corporations, such as
All At Once And None At All
Yet the notion that a weak global economy and a conspiracy of industrial lobbyists prevented progress at the UN meeting is wrong. As currently pursued, international efforts on NCDs would also fail to generate support in a good economy -- as they have since the WHO first reported the emerging epidemic of NCDs. The effectiveness of corporate lobbying at the UN meeting was a symptom of poorly conceived collective action on NCDs, not its cause.
Collective efforts against NCDs have failed because of the disparate nature of these diseases and the decision to try to address them on a global level. In addition to cancer, diabetes, cardiovascular disease, and respiratory illnesses, NCDs include a wide array of conditions, such as skin diseases, congenital anomalies, mental disorders, rheumatoid arthritis, and dental decay. These diseases are not all chronic, related to unhealthy habits, or even noncommunicable. As a class, NCDs have little in common other than being the diseases that become more prevalent as a population reduces the plagues and parasites that kill children and adolescents. NCDs are, in short, the diseases of those with longer lives.
Trying to address these diseases as a single class and on a global level has both broadened opposition and diffused support for effective action. On one hand, addressing NCDs as a single category has united a wide array of otherwise disconnected industries, from agriculture to pharmaceutical companies and restaurants, against global targets to reduce NCDs and their risk factors. On the other hand, it has made it difficult to mobilize states and sufferers of NCDs worldwide around a specific and meaningful policy agenda. And when NCDs are presented as imposing the same challenges in developed and developing countries alike, policymakers and potential donors are apt to conclude that they cannot be solved by international action and are simply the natural consequence of economic development.
To move forward, the international community should focus on the NCDs and risk factors especially prevalent among the developing-country poor and on the particular needs of their governments to address them. This targeted approach would build stronger international support for concrete action while minimizing the number of potential opponents.
Tobacco offers a good place to start. According to the WHO, tobacco use already kills more people annually than HIV/AIDS, tuberculosis, and malaria combined. In the coming decades, it is projected to debilitate and kill hundreds of millions more, largely in low- and middle-income countries. Tobacco use is the only leading risk factor common to all the major groups of NCDs: cancer, diabetes, cardiovascular illness, and respiratory dysfunction. By increasing support for tobacco control in developing countries, the international community could help reduce one of the most significant threats to global health today.
Fortunately, a platform for combating tobacco use already exists: the
These programs are making progress, but they are limited by a lack of funding and technical capacity within developing countries, as well as fierce industry opposition. Outside the handful of developing countries that receive support from Bloomberg Philanthropies and the
Meanwhile, international initiatives to reduce the intake of alcohol, trans fats, and salt should focus for the time being on existing programs and partnerships with suppliers and retailers designed to make their beverages and food healthier. These voluntary measures may not replace the need for taxes and regulations in these areas, but they could promote progress until the capacity and popular support for such programs grows. When that time comes, the improvements made in country-level regulatory and taxation systems for tobacco control could be extended to address alcohol, trans fats, salt, and other NCD risk factors. Integrating the monitoring of alcohol and unhealthy food consumption into the existing international tobacco-surveillance system would also offer a cost-effective means of collecting evidence on the implementation of the initiatives in these areas.
Yet prevention measures alone cannot solve the NCD problem. Expanding existing international vaccine-procurement mechanisms to include essential medicines for NCDs would help developing countries obtain the supplies necessary to meet the needs of their citizens. More donor support is required for product-development partnerships, such as the international organization PATH, which is working to adapt existing medical technologies for NCDs for use by low-income countries.
Finally, the international community should not forget the poorest countries, where the consumption of unhealthy products is low and tobacco-prevention programs would offer only limited benefits to those suffering from cancer, diabetes, and other NCDs. International NCD efforts should aid these countries by supporting the expansion of existing treatment programs, such as those established in
From Village To Slum
Global health needs are changing. The NCD crisis in developing countries represents one part of a set of growing health challenges, from food safety and environmental pollution to road safety and substandard medicines, now replacing infectious diseases as the major causes of premature disability and death worldwide. These other challenges share similar origins as NCDs -- freer trade, unprecedented urbanization, and limited local government capacity -- and likewise have devastating consequences for the world's poor.
Whether targeting NCDs one by one or approaching them comprehensively, the international community will depend on
To meet this challenge,
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