UN mobilizes global governments in fight against non-communicable diseases

During the opening remarks at the U.N. High-level Meeting on Non-communicable Diseases, held from Sept. 19 to 20 in New York, Margaret Chan, MD, MPH, director-general of WHO, described the escalating epidemic of non-communicable diseases as a “slow-motion disaster.” If the crisis is not addressed now, she said, it will eventually outpace even the best efforts toward treatment and prevention.

“We know the statistics and the ominous trends that now encircle the globe,” Chan said. “We know what lies ahead.”

Chronic conditions, including diabetes, cardiovascular disease, cancer and chronic respiratory disease, account for 63% of deaths worldwide, or approximately 36 million of 57 million deaths annually. These numbers are projected to increase by 17% in the next decade, according to U.N. Secretary-General Ban Ki-Moon.

Nevertheless, the landmark, 2-day meeting is a first step toward declaring war on these conditions, Ban said. The meeting represented only the second time in history, since the HIV/AIDS Summit in 2001, in which the U.N. convened to discuss a health-related issue.

Ann Keeling

“The meeting brought together 34 heads of state; 133 member-states made statements; and there were a record number of civil participants,” Ann Keeling, chair of the NCD Alliance and CEO of the International Diabetes Federation (IDF), told Endocrine Today. “It showed the world that non-communicable diseases, including diabetes, are now on the global agenda.”

At the conclusion of the opening session, the General Assembly accepted without vote the U.N.’s political declaration to adopt a coordinated effort to tackle the growing issue of non-communicable diseases. The declaration highlights the importance of prevention; international cooperation; increased surveillance, monitoring and evaluation; improving health resources; and adopting a “whole-of-government and whole-of-society” approach, according to the document.

“This will be a massive effort, but I am convinced we can succeed,” Ban said.

The meeting also served as a call to arms for policymakers, industry members and non-governmental organizations, three integral entities in the fight against non-communicable diseases, according to Chan. Medical and health professionals are well aware of the threat that chronic conditions pose, she said; however, others, including government officials, may not understand how their involvement can be a game-changer.

“The problem is too big and too broadly based to be addressed by any single government ministry. Because the rise of these [non-communicable] diseases is being driven by powerful, universal forces, like rapid urbanization and the globalization of unhealthy lifestyles, the response to these trends must come with equal power, with top-level power that can command the right protective policies across all sectors of government,” Chan said.

‘An immense human burden’

Non-communicable diseases already claim many lives and take a heavy toll on patients and health care professionals. Unfortunately, projections from various studies and organizations indicate that, without proper action, the problem may escalate.

For example, diabetes affected 366 million people and caused 4.6 million deaths worldwide in 2011, according to Diabetes Atlas figures released by the IDF at the European Association for the Study of Diabetes 47th Annual Meeting in Lisbon. If current trends persist, estimates from the fourth edition of Diabetes Atlas suggest that the number of people with diabetes will escalate to 438 million by 2030. Likewise, data from the CDC project a doubling in the number of newly diagnosed cases of diabetes in the United States and approximate a surge in prevalence from 14% to about 21% by 2050.

Similarly, rates of obesity, a significant risk factor for various non-communicable diseases, are also increasing. Results from a report published by Y. Claire Wang, MD, of the Mailman School of Public Health at Columbia University, New York, and colleagues suggest that the number of obese Americans will rise from 99 million to 164 million by 2030. According to this study, these growing numbers may lead to 7.8 million more cases of diabetes, 6.8 million more cases of coronary heart disease and stroke, and 539,000 more cases of cancer. Comparable conclusions were drawn from data on the U.K. population. There, the number of obese adults will grow from 15 million to 26 million by 2030, resulting in 668,000 additional cases of diabetes, 461,000 additional cases of CHD and 13,000 additional cases of cancer among adults, Wang and colleagues wrote.

Although these figures are alarming, representatives at the U.N. meeting said statistical forecasts need not become reality. Affordable interventions and strategies exist, but stopping the diseases before they start is at the heart of these plans.

“We are looking at something that not only has rising incidence, but also presents a very substantial economic burden and, even more so, an immense human burden in terms of avoidable mortality and morbidity,” Andrew Lansley, CBE, MP, U.K. secretary of state for health, and leader of one of three round table discussions, said during the meeting. “We recognize that we must deal with some of those specific health challenges and build our health systems’ capacity to respond to that, not only in terms of treatment but also in refocusing our efforts toward prevention.”

Paying the price

Although data on morbidity and mortality perhaps paint the most sobering picture of the detrimental effects of chronic diseases, economic and financial analyses reveal that these illnesses also hinder national development and growth.

“Headline results of [a new WHO study sponsored by the World Economic Forum] state that [diabetes, CVD, cancer, chronic respiratory disease] and mental health will cost the world $47 trillion in the next 2 decades,” David Bloom, PhD, of the Harvard School of Public Health, said during the first round table meeting. “That is 4% of the global gross domestic product; 10 times the number of public and private monies spent on health on an annual basis; and 25 times the amount of overseas development assistance over the last 20 years.”

When broken down according to individual disease, the report shows that the global cost of diabetes in 2010 was approximately $500 billion and could escalate to $745 billion by 2030.

“Non-communicable diseases matter a lot now to the pace and process of economic development,” Bloom said. “They will matter a lot more in the future as the economic burden grows to staggering proportions.”

Vicious cycle

A previous WHO report indicated that about 80% of the 36 million deaths attributable to non-communicable diseases occurred in low- and middle-income countries, an outcome that has serious ramifications for developing nations. Consequently, health care providers, non-governmental organizations and policymakers have become additionally concerned about nations that may not be able to absorb the cost of treatment.

Results from the study performed by Bloom and colleagues showed that middle-income countries will experience the sharpest increase in costs related to chronic conditions. In fact, the researchers said, non-communicable diseases will impose a $7 trillion burden on low- and middle-income nations in the next 15 years.

“Families, countries and companies are losing people in their most productive years,” a representative from the World Economic Forum said at a round table discussion. “Our report shows that non-communicable diseases have the potential to not only bankrupt the health system, but also put a break on the global economy, which is not what we need in today’s volatile economic situation.”

Moreover, on an individual level, non-communicable diseases account for a considerable amount of patient and family incomes. In India, for example, the costs of treating diabetes consumes 15% to 25% of a patient’s household earnings. These patients may become trapped by circumstances that only serve to perpetuate poverty, as the disease often impedes their ability to work or causes people to leave jobs to care for ill family members, according to Robert Beaglehole, DSc, of the University of Auckland, New Zealand, and colleagues.

“These are the diseases that break the bank,” Chan said. “Left unchecked, these diseases have the capacity to devour the benefits of economic gain.”

An international issue

Nevertheless, there is an upside to combating non-communicable diseases, speakers at the meeting said. Unlike with other illnesses, people have the potential to stave off the development of certain chronic conditions, including diabetes, CVD and cancer.

“Treating non-communicable diseases can be affordable, but preventing them can cost next to nothing,” Ban said during a plenary session. The WHO study conducted with the World Economic Forum supports Ban’s assertion. After examining a variety of measures implemented by countries during the past 10 years, researchers found that population-based interventions, such as taxes on tobacco and alcohol, smoke-free indoor workplaces and campaigns to improve diet, cost only 20 cents per person per year in low-income and lower-middle-income countries and approximately 50 cents per person per year in upper-middle-income countries.

Ala Alwan

“Implementing [these cost-effective strategies] would save literally millions of lives over the next 15 years,” Ala Alwan, MD, PhD, assistant director-general for non-communicable diseases and mental health at WHO, said in a press release issued by the organization.

During the meeting, representatives focused on four major factors that intensify the risks for non-communicable diseases: poor nutrition; lack of physical activity; tobacco use; and excessive alcohol consumption. Tackling these issues forms the basis of all preventive strategies, they said.

Even so, aggressive marketing campaigns, coupled with the low cost of processed foods with high sugar, fat and salt content, have increased the popularity of these products in poorer countries, several representatives said. Further, it is difficult to curtail tobacco use because smoking is a status symbol in some cultures or cigarettes are simply inexpensive in certain areas. For other nations, safe spaces for exercise are an issue.

Admirable efforts

Although an uphill battle, many countries are trying to reduce their rates of non-communicable diseases. The president of Mexico reported a partnership with the Fédération Internationale de Football Association (FIFA), the international governing body of soccer, to expand areas where children can participate in sports such as soccer. In Kenya, President Mwai Kibaki described legislative efforts to regulate smoking in public places and enforce restrictions on alcohol consumption.

“[This meeting] led to commitments to promote healthy diets and increase physical activity through urban planning, active transport and work site healthy lifestyle programs,” Keeling said. “No targets have been agreed upon, but [many] governments have taken a step forward and committed to reducing salt, sugar and saturated fats, and eliminating industrially produced trans fats in foods.”

Keeling said there is now a strong focus on reducing childhood obesity and developing better reproductive, maternal and newborn child health programs.

However, many representatives, including those from lower-income areas of the world, said their countries still need help. In his concluding speech, Denzil L. Douglas, prime minister of St. Kitts and Nevis, outlined several factors needed to accomplish these goals, such as strengthening national surveillance, and regional and international sharing of information to provide concrete data about the severity of non-communicable diseases in various areas. It is also important to inform heads of state, health ministries and researchers about which interventions prove most effective and which areas require more attention.

International cooperation will aid lower- and middle-income countries in their regulatory battles regarding advertising and marketing of alcohol and tobacco, as well as marketing of unhealthy foods to children, according to Douglas. This coordination may also bolster their ability to negotiate with the pharmaceutical industry for more affordable medications.

Finally, international organizations such as the U.N. and WHO will be essential in aiding nations to secure the necessary financial and social support that has so far impeded certain countries from obtaining the help that they need, Douglas said. Other speakers spoke about the importance of improving health care systems, increasing access to care and scaling up primary care practices to successfully screen and treat patients, especially when specialty clinics are unavailable.

“Politicians need to be confronted with a strong sense of outrage; people with these diseases must stand up and demand their right to health and the right to universal access to medicines,” Keeling said. “No more should we accept accidents of geography that determine whether people with diabetes live or die. Insulin was discovered 90 years ago, but children in low-income countries are dying from type 1 diabetes, while in high-income countries, they can live long and healthy lives.”

More than words

Despite progress made during the meeting, some said they feel that the declaration accepted by the U.N. calls for war, but offers no battle plan.

“The major weaknesses of the declaration are the lack of time-bound targets to shape a shared political vision for the future and the failure to agree on a high-level, multisectoral partnership to drive follow-up action,” Keeling said, adding that meeting leaders pushed back structuring a comprehensive global monitoring framework for these diseases to 2012. “Another weakness — while not surprising in the current global economic climate — is the lack of concrete commitments on resources. The declaration recognizes that resources for dealing with non-communicable diseases fail to match the magnitude of the problem, but it only requests member-states to investigate options for funding.”

Nevertheless, Keeling found merit in the document’s message and commitments made at the meeting. A review is scheduled for 2014, during which member-states will examine progress made on the goals set in 2012.

“Two years ago, it was inconceivable that diabetes and other non-communicable diseases would have achieved today’s prominence without the catalyst of the summit. With courage, leadership and long-term vision, a new future is possible for people with diabetes and non-communicable diseases.”

During the meeting, Ban urged U.N. member-states to remember the significance of their actions, underscoring the fact that the aftershocks of how they approach the problem of non-communicable diseases will be felt in the years to come.

“If the document remains just a set of words, we will have failed in our obligation to future generations,” he said. “But if we can give meaning through tough actions, we will have honored our responsibility to safeguard our shared future.” – by Melissa Foster

For more information:

• Beaglehole R. Lancet. 2011;378:449-455.
• Bloom DE. The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum; 2011.
• International Diabetes Federation. Diabetes Atlas, 4th ed. Available at: www.idf.org/diabetesatlas. Accessed Oct. 5, 2011.
• Jemal A. CA Cancer J Clin. 2011;doi:10.3322/caac.20107.
• Wang YC. Lancet. 2011;378:815-825.

Disclosure: Disclosure information was not made available at the meeting.

Alan J. Garber

Because of the success in public health arenas and with antimicrobial therapy, communicable diseases, which were once the leading cause of death and long-term disability in the world, have declined worldwide. What we have now is an excess of social diseases, or non-communicable diseases, that are largely grouped as metabolic or obesity-related.

One major problem is that we live in an era in which food is readily available because of refrigeration and preservatives. Our lifestyles are also becoming increasingly less active. Consequently, physiologic mechanisms, which regulate appetite, once encouraged us to eat and hold onto every calorie in case of famine. These mechanisms, however, are now redundant to our current lifestyle. But, unfortunately, our bodies are not going to adapt that quickly. Food selection is another issue. People like high-fat, high-carbohydrate, calorie-dense foods, and there are very strong hypothalamic mechanisms that reinforce and drive appetites and cravings. Therefore, the demand for these products is high, and producing them becomes more profitable than producing other, healthier foods.

Government interventions until now have not been extraordinarily successful, but efforts can still be made. Implementing physical education as part of school curricula may encourage more exercise among children. In addition, culturally removing the stigma from obesity would help patients to not move backward and instead be encouraged to become healthier.

– Alan J. Garber, MD, PhD

Endocrine Today Chief Medical Editor

Disclosure: Dr. Garber reports no relevant financial disclosures.

L. Samuel Wann

Obesity, diabetes, cancer and CVD are all very important diseases that affect not only our patients in the US, but also are found in increasing incidence around the world. It is eye-opening for American physicians that the U.N. made it a priority to address these problems in the developing world, as well as in wealthier countries, and to consider how to mitigate these problems. These illnesses that are now reaching epidemic proportions in other parts of the world are also ones that we struggle with in the US. Major risk factors, such as poor diet, excess calorie and alcohol consumption, lack of exercise, and exposure to environmental toxins, including smoking, that lead to the development of all of these chronic diseases are present everywhere. There are no easy solutions to eliminating them, either in the United States or other countries. Public policy and education, however, can be extremely helpful. The answer is not force, but rather education and making healthy choices easy, not hard. For example, taxing soft drinks or promoting walking and cycling rather than developing cheaper gasoline, particularly in countries where having a car is difficult anyway, may also be beneficial. In addition, as we deal with an aging population, we should become more realistic about the economics of medical care and “rational” rationing of care, based more on what is effective in reducing death and disability, rather than on how much a patient can afford to pay. In some situations, people may want to have cardiac surgery and advanced chemotherapy before they have clean water or effective anti-smoking policies. Unfortunately, outsiders cannot simply go into another country and promoted high-tech procedures such as coronary angioplasty and expect to make much of a difference. Instead, we should endorse changes in lifestyle — at home, as well in other countries. We cannot force people to adopt health lifestyles, but we can certainly help as facilitators.

– L. Samuel Wann, MD

Chairman, Department of Cardiovascular Medicine

Wisconsin Heart Hospital

Disclosure: Dr. Wann reports no relevant financial disclosures.

John R. Seffrin

The U.N. High-level Meeting is very important because it recognized that non-communicable diseases will be the health disease and disability challenge of the 21st century. Cancer is already a leading cause of death worldwide — and its toll will continue to rise — if we do not intervene. If we do intervene, however, it could conceivably be the first chronic disease brought under control during the 21st century.

During a separate meeting that I attended for the Clinton Global initiative, we secured a commitment between several organizations, across multiple sectors, who will be working together to encourage companies worldwide to make their workplaces 100% smoke- and tobacco-free. Actions are also being taken, and more will be as they become available, for using the human papillomavirus vaccine, especially in poorer countries, to protect women against cervical cancer. Additionally, we need to understand that people whose cancers cannot be prevented or are not detected early enough for a cure need access to palliation and quality care throughout the experience. For example, Uganda had no analgesics for the better part of last year; now, there is a surplus, thanks in part to our work through the Global Access to Pain Relief Initiative. Pain control is not something that will break the bank.

Cancer is potentially one of the most preventable and most curable of the major life-threatening diseases facing humans. Our job is to turn that potentiality into a reality for people everywhere. With the research we have and the efforts that have been made, we now save 350 lives per day in the United States that would have been lost to cancer. But we could eventually save 10,000 lives per day, globally. There is no reason we cannot achieve that and intervene with the right policies and access to quality health care.

– John R. Seffrin, PhD

CEO, American Cancer Society

Disclosure: Dr. Seffrin reports no relevant financial disclosures.