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.

Margaret Chan

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 — that the U.N. convened to discuss a health-related issue.

“There were 133 member-states present and 34 heads of state, more than the number present at the HIV/AIDS Summit,” John R. Seffrin, PhD, CEO of the American Cancer Society, told HemOnc Today. “It gave us a wake-up call that we have to do something because, if we do, we can not only save a lot of lives and reduce a lot of human suffering, but we can also improve the economic prospects of our future as well.”

At the conclusion of the opening session, the U.N. 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.

According to the Global Cancer Facts and Figures from the ACS, 7.6 million of the 57 million deaths per year attributable to non-communicable diseases were related to cancer. By 2030, this number is projected to reach 13.2 million. A global rise in incidence is expected as well, with the burden increasing to 21.4 million new diagnoses per year, the report states.

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, and colleagues suggest that the number of obese Americans will rise from 99 million to 164 million by 2030. According to this study, this growing number may lead to 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 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 as well.”

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, cardiovascular disease, 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 cancer in 2010 was approximately $290 billion and could escalate to $458 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.

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.

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 consume 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, cardiovascular disease and cancer.

“Unlike with HIV/AIDS, these diseases are not a mystery,” Seffrin said. “We have strong evidence now that cancer is potentially one of the most preventable and the most curable of the major life-threatening diseases facing human beings, and our job is to turn that potential into a reality for all people everywhere.”

John R. Seffrin

During a plenary session, Ban said prevention is even more affordable than treatment. 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.

“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.

Throughout 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.

Admirable efforts

Although an uphill battle, many countries are trying to reduce their rates of non-communicable diseases. For example, President Mwai Kibaki described legislative efforts in Kenya to regulate smoking in public places and enforce restrictions on alcohol consumption.

“During a 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,” Seffrin said. Actions are also being taken to make the vaccine for HPV, a major cause of cervical cancer, more available in lower-income areas.

In addition, Seffrin said a need exists for “access to palliation and to quality care throughout the cancer experience.” Many countries lack even the most basic resources, but because of efforts from various organizations, he is hopeful. For instance, Uganda had no analgesics for pain management for the better part of last year. Now, however, they have a surplus.

Still, 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. However, 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.

“We can work with the government and we can work with the private sector,” Seffrin said. “The key point is, yes, money is important, but we can’t afford to wait until the economy is improved to take action. We need to start where we are, use what we have and do what we can. And there’s a lot we can do with the resources we already have at our disposal.”

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. “Crucially, the declaration lacks tangible targets,” according to an editorial published in The Lancet Oncology. “The outcome document should have included a set of feasible actions and interventions with specific deadlines and indicators upon which progress will be measured.”

Nevertheless, Seffrin said the document produced positive outcomes. WHO has the responsibility of developing metrics and goals that are measurable by the end of 2012, which will lead to important changes.

“We need to understand that this is not a panacea. It doesn’t solve the problem,” he said. “But it provides us now with a platform and an official document that points out that this is the major health disease and disability challenge for the 21st century, and therefore, we need to take action.”– by Melissa Foster

For more information:

• American Cancer Society. Global Facts & Figures 2nd Edition. Atlanta: American Cancer Society; 2011.
• Beaglehole R. Lancet. 2011;378:449-455.
• Bloom DE. The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum; 2011.
• International Diabetes Foundation. 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.
• Lancet Oncol. 2011;doi:10.1016/S1470-2045(11)70272-8.
• Wang YC. Lancet. 2011;378:815-825.

Disclosure: Disclosure information was not made available at the meeting. Dr. Seffrin reports no relevant financial disclosures.

Tanja Cufer

The drafting of the political declaration involved regional conferences held during the previous year with input from the non-governmental sector. The basic principles and guidelines for controlling non-communicable diseases worldwide outlined in the document will enable member-states, governments and organizations to create their own, new non-communicable disease-based politics. One of our biggest benefits lies in the fact that all countries, some to a larger extent than others, already have well-established structures and politics for these diseases and cancer control.

Importantly, the declaration also emphasizes equality in access to early detection and treatments, naturally tailored to each country’s capabilities, and underscores the significance of stimulating and carrying out research. The rising incidence of cancer, especially in less developed countries, will lead to a lack of well-trained personnel as well as financial deficits. Each society as a whole will therefore have to form sets of priorities on how to put the limited resources, both in terms of staff as well as funding, to optimal use. In addition to oncologists, other medical and nonmedical professionals will have to be included in the processes of cancer control.

Since there is little point in each country starting from scratch in terms of preventive strategies, the concept of international transfer of knowledge and expertise was a very well laid out and accepted idea discussed at the meeting. We must learn from each other what works and later transfer this knowledge to new surroundings and regions, tailoring the approaches and solutions to the specific needs of the new environments.

The political declaration adopted at the U.N. summit is only the first step. A large amount of work and effort still remains.

– Tanja Cufer, MD, PhD

Professor of Oncology, Medical Faculty Ljubljana

Senior Councilor, University Clinic Golnik, Slovenia

Chair, ASCO International Affairs Committee

Disclosure: Dr. Cufer reports no relevant financial disclosures.

Dale Shepard

This meeting was significant because there’s been a need to get all the players, meaning researchers, the pharmaceutical industry, government payers and more, at the table to address treatment and, even more importantly, prevention of cancer. We can make tremendous strides in lower-income areas both in the US and around the world by simply pushing for lifestyle change, including smoking cessation, reduced alcohol consumption and better nutrition.

Prevention is also important when one takes a global view of how we treat cancer. Many recently approved cancer therapies are very expensive but provide little benefit. Even in the US, a patient may wait at least a month to start therapy while they try to gather financial support for treatment. By comparison, prevention is far less expensive.

We need to place more emphasis on effective screening as well because prevention and screening go hand in hand. Early detection translates to earlier therapy and expanded treatment options. Further, after analyzing research utilization on a global scale, screening programs are relatively inexpensive and may be easier to implement than other interventions, such as vaccination, in lower-income areas.

Additionally, refocusing our priorities for research into therapies will be essential to advancing our ability to effectively treat cancer. Unfortunately, there are many trials that aim for noninferiority as opposed to superiority. We need to change this mindset. Understandably, pharmaceutical companies feel a great deal of pressure to have their products approved, but we will never cure cancer until we work together to develop better goals.

– Dale Shepard, MD, PhD

Staff oncologist

Cleveland Clinic

Disclosure: Dr. Shepard reports no relevant financial disclosures.