Although noncommunicable diseases (NCDs), like heart disease and cancer, account for more than half of annual deaths worldwide, they have received much less attention among the international community than infectious diseases like malaria. What actions are needed to galvanize government action to reduce the prevalence of NCDs?
Many of the myths surrounding noncommunicable diseases (NCDs) are being exploded. The most common was that these were problems of the rich, developed world and the countries of the developing world would have to deal with them only as their economies grew. Well, times have changed: recent data show that NCDs like heart disease, cancer, and diabetes are responsible for more than 50 percent of the global burden of disease. In 2005, the most recent year that data are available, an estimated 80 percent of chronic disease deaths occurred in low- and middle-income countries in Africa, parts of Asia, and Latin America. The proportion of deaths from NCDs globally is projected to be 69 percent by 2020, and in India, for example, cardiovascular disease is now the leading cause of death. Even though infectious diseases are still common, the last year in which deaths from communicable diseases like malaria and tuberculosis outnumbered those from NCDs was 1998.
Striking statistics like these have led to increased interest in NCDs internationally. The Global Alliance for Chronic Diseases, made up of major research institutes in Australia, the United States, Great Britain, Canada, and China, is coordinating research that addresses the prevention and treatment of chronic diseases and developing the evidence base needed to guide policy, identify best practices, and foster sustainable reductions in the rates of illnesses, disability, and death around the world. T
The World Health Organization (WHO), in its Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, 2008–2015, the WHO Framework Convention on Tobacco Control, the Global Strategy on Diet, Physical Activity and Health, and the evidence-based strategies and interventions to reduce the public health problems caused by the harmful use of alcohol all emphasize the need to integrate prevention and control of NCDs into policies across all government departments. These diseases have common risk factors (unhealthy diet, physical inactivity, tobacco, and harmful use of alcohol) with political, economic, social, gender, behavioral, and environmental determinants therefore requiring multisectoral responses.
If only people would change…
Another myth about controlling NCDs is that it’s about freedom of choice. Standard health promotion dogma for many years has been to argue for modification of individual behavior under the guise of getting people to change their lifestyles with regard to the predominant risk factors—smoking, unhealthy diets, and lack of physical activity. But serious questions have arisen about the effectiveness of this strategy in developed countries. And is it appropriate to export the failure of this approach, at least in the case of the cardiovascular disease, to developing countries?
If true progress is to be made, intervention must also happen at the population level. A successful approach will require significant alteration of the external enabling environment, through efforts like increasing the sale price of tobacco, banning transfats, and mandating physical education in schools in order to modify the risk factors that are common to most of these chronic diseases. According to recent estimates, doing so could reduce mortality from NCDs by some 80 percent. It is also accepted wisdom that the levers needed for change in the enabling environment lie squarely in the hands of governments and can be affected through the instruments that they control—legislation, regulation, and taxation.
These levers are not in the hands of the ministries of health. As Ebrahim and Smith (see Further Reading) put it succinctly, “The failure of governments to make often difficult decisions about tobacco, alcohol and food pricing and its availability is a more powerful determinant of cardiovascular disease risk than the failure of individuals to heed health education messages.”
In developing countries, ministries of health are traditionally seen as a mendicant to other loci of power in the government. The level of inattention stems in part from the perception of health not being truly instrumental for development as conventionally construed and by the overwhelming attention given to systems of health care. In the systems of government with which we are most familiar, genuine intersectoral action can only come when it has the approval of or is mandated by the head of state.
Understanding of the loci in government at which the critical decisions are made and the process by which public policy is formulated is as important for the prevention and control of NCDs as is the collection of epidemiologic data about the diseases and their risk factors. We would contend that this appreciation is perhaps more necessary in the case of the NCDs. There is not the fear of contagion that often drives action in the case of the communicable diseases nor do NCDs have the dramatic presentations of communicable diseases—heart attacks don’t inspire public outcry. Because they are chronic, NCDs often escape the careful attention of governments focused on time periods that are influenced by political cycles. In addition, no organized powerful constituency of the interested and affected exists, as is the case with HIV. A measure of the inattention is the lack of funding from major philanthropic foundations, which studiously ignore NCDs.
Overturning another myth
In attempting to help craft the public policy that will result in effective government interventions, the first requirement is to erase from discourse the shibboleth that there is lack of political will. The problem more often is a lack of appropriate prerequisites for making the needed policy. These include technical and political champions, in collaboration with the private sector, civil society, and international agencies to engender a political response through appeals to the head, the heart, and the pocket (sound epidemiological data, evidence of human suffering, and data on the developmental and economic impact of NCDs). In the analysis of costs versus benefits, those who are most likely to benefit are often the most mute and unable to effect change.
The progress of the countries of the Caribbean community (CARICOM) toward action and advocacy at the level of heads of government illustrates the confluence of the three elements necessary for political action: the problem stream, the policy stream, and the political stream. The CARICOM heads of government in 2001 declared that “the health of the region is the wealth of the region.” To give effect to the declaration, they established the Commission on Health and Development, which on the basis of epidemiological and economic data, identified NCDs as the major health problem confronting the region.
Presentation of findings to the individual cabinets of the 15 governments and having a credible champion—one of the standing prime ministers—were the essential steps for getting the item on the collective governmental agenda. It was not enough to articulate the problem in health, economic and human terms, but solutions were proposed toward healthy public policy. The result of these processes was a Summit of Heads of Government in 2007 to discuss NCDs exclusively and emit a 15 point declaration on the policies that would be adopted regionally.
So convinced are they now of the importance of the NCDs being considered at the highest political level, the CARICOM leaders have sponsored a declaration by the 52 Commonwealth Heads of Government calling for a UN summit to address the problem. The Caribbean politicians envisage the summit as emphasizing and highlighting the enormity of the problem at national, regional, and global levels, providing the forum for agreement on the magnitude of the global response necessary and involving the other major social partners—international agencies, including the donor community, and at national level, the private sector, including pharmaceutical companies and food manufacturers, and civil society, including universities and consumer groups and the media, in the efforts to prevent and control these diseases.
None of this runs counter to the need for acute and chronic care for NCDs, or the appropriate secondary prevention that will undoubtedly reduce mortality and morbidity. This is merely an attempt to illustrate the imperative for action at the highest levels of government to create the necessary public policy for the prevention and control of NCDs.
Sir George Alleyne currently serves as United Nations Secretary-General's Special Envoy for HIV/AIDS in the Caribbean.
T. Alafia Samuels is the project head of Pan American Health Organization.
Ebrahim S., G.D. Smith. 2001. Exporting failure? Coronary heart disease and stroke in developing countries. International Journal of Epidemiology. 30: 201–205
Kingdon, J.W. 2003. Agendas, Alternatives, and Public Policies. Second edition. Glenview, IL: Addison-Wesley Educational Publishers Inc.
Lopez A.D., C.D. Mathers, M. Ezzati, D.T. Jamison, and C.J.L. Murray. 2006. Global Burden of Disease and Risk Factors. Cambridge and Washington: Oxford University Press and the World Bank.
World Health Organization. 2008. Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable disease 2008-2013.WHO Document A61/8. April.