Medical journalist Paul Webster analyzes the implications of the WHO’s 2013-2020 NCDs Global Action Plan.
It was September 2011 and world leaders were at the UN headquarter in New York to confront a vast global health problem. The issue was chronic diseases such as cancer, diabetes, and cardiovascular and respiratory diseases. According to the UN, these non-communicable diseases (NCDs) are associated with 36 million deaths annually. And 80% of these deaths occur in developing nations with limited resources to prevent them, United Nations Secretary General Ban Ki-moon bluntly warned an audience of hundreds of heads of state and senior government leaders, including Canadian Health Minister Leona Aglukkaq.
“The prognosis is grim,” Ki-moon continued. Worldwide deaths from NCDs are expected to increase by 17% over the next decade, and by 24% in Africa. As a result of a global shift toward the consumption of processed foods rich in salt, sugars and trans fats, Ki-moon explained, the incidence of NCDs in poor countries is now disproportionately higher than in rich ones. Global obesity levels have doubled since 1980, he added. “This is a slow-motion disaster spreading with stunning speed and sweep,” Ki-moon warned.
Noting that the most common NCDs can be largely prevented or controlled by tackling shared risk factors including tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol, as well as through early detection and treatment, Ki-moon had some blame to place: “There is a well-documented and shameful history of certain players in industry who ignored the science — sometimes even their own research — and put public health at risk to protect their own profits,” Ki-moon said before urging “corporations that profit from selling processed foods to act with the utmost integrity.”
Spurred on by Ki-moon’s warnings at the 2011 summit, UN member states unanimously voted to task the World Health Organization with expanding global NCD surveillance and developing a set of global targets before the end of 2012 to monitor trends and progress in the battle to reduce NCDs.
The WHO followed-up swiftly: In November 2012, it produced a Global Monitoring Framework including 25 indicators and a set of 9 voluntary global targets for prevention and control of NCDs -- including the goal of a 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025 -- that was approved by 119 member states, the European Union and 17 NGOs. Then, in late May of this year, the WHO’s Global Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 was approved by the World Health Assembly. In September, the Plan will be reported back to the UN General Assembly.
Much of the credit for the WHO’s rapid progress in mobilizing global efforts to tackle the rising tsunami of chronic diseases goes to Dr. Tim Armstrong, a soft-spoken Australian who serves as Coordinator for Surveillance and Population-based Prevention in the WHO’s Department for the Prevention of NCDs in Geneva, Switzerland.
In a recent interview in Geneva, Armstrong described the WHO’s Global Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 as an achievement in global health diplomacy that attempts to be of equal utility to all UN member states – rich or poor.
It’s a discussion in which money matters loom large, Armstrong notes: according to WHO estimates, the average yearly cost to implement a core set of high-impact NCD prevention treatment interventions for all low- and middle-income countries would be $11.4 billion, while the economic impact of NCDs in these countries is an estimated $500 billion. Over the period 2011-2025, the cumulative lost output in low- and middle-income countries due to NCDs is projected to be $7.28 trillion.
But because the WHO is not a funding agency, Armstrong stressed, it will have to raise money to help poor countries – especially those with huge populations and high NCD burdens such as Bangladesh, Indonesia, India and Nigeria – invest in health and social reforms and NCD surveillance tools. “We need support from donors. We are requesting that countries that have the capacity invest in helping those that do not.”
Money isn’t the only thing that is scarce, Armstrong stresses. The WHO process also depends on data, he emphasised – much of it of a sort that simply doesn’t exist in many countries. “What gets measured gets done,” he quipped. But measuring many of the risk factors for NCDs is difficult, he explained, because many are external to healthcare – things like athletics, urban design, transportation, and the amount of time people spend watching television. “The availability of data on a range of NCD outcomes and risk factors and capacities is quite limited. And there are many high income countries where we don’t have good data whereas in middle income countries where we have been able to get in and do surveys we may have better data.”
In Ottawa, Blossom Leung, a spokeswoman for Health Canada, says “Canada intends to work closely with the WHO on a global mechanism to coordinate NCD action and to share innovative and effective practices.” Canada will also be actively participating in concurrent consultations by the WHO on its engagement with NGOs and business interests, Leung added.
“We need support from donors. We are requesting that countries that have the capacity invest in helping those that do not.”
As Armstrong acutely knows, the WHO Plan will both please and disappoint many expert observers. Vivian Lin, Chair of Public Health at La Trobe University in Melbourne, Australia, says the WHO’s effort inevitably resulted in a very broad accommodation of interests and issues – including the business interests of food and beverage and pharmaceutical companies -- that doesn’t “deal with the hard things that have to be done.” She describes the NCD Plan as “workmanlike” compared to earlier WHO global plans such as its “visionary” 1978 Alma Ata declaration on the universal need for access to primary healthcare. And she notes that the WHO’s International Code of Marketing of Breast-Milk Substitutes and Framework Convention on Tobacco Control were much more strident in identifying and confronting industries associated with NCDs.
David McQueen, who served as Associate Director for Global Health Promotion at the Centers for Disease Control in Atlanta, U.S.A. until 2011, feels the NCD Plan suffers from a lack of direct guidance on how to achieve NCD control. “It’s not really an action plan,” he worries “it’s a set of guidelines.” He also thinks the WHO’s approach to NCD surveillance is outdated and overlooks new approaches that include social determinants of health. But he describes the Plan as “impressive” nonetheless.
Suzanne Jackson, professor of global health and head of the WHO Collaborating Centre in Health Promotion at the University of Toronto thinks the indicators and targets in the Plan are well chosen. Her main critique is that the WHO has prioritized the need for individuals to change their lifestyles over the need for more sweeping societal changes that will curb NCD risk factors. The biggest drivers of all – trade in food and beverages and drugs, and environmental hazards like air pollution and toxins – are barely hinted at, she notes.
For the WHO to succeed reducing the NCDs, Jackson, McQueen, Lin and Armstrong all agree, countries and corporations are going to have to get behind its Plan. But that may not lead to big changes. “They’ve got a set of policy options for member states that are pretty high level,” says Jackson and adds:
“But many people may say there’s not a lot here to get people to actually do it.” <>
NCDs in a developing country
With few financial resources, Columbia is using innovative solutions to meet the WHO’s Global Action Plan. Paul C. Webster visited the country and explains the challenges.
As many developing countries are discovering, the wave of chronic and noncommunicable diseases that stem from conditions like obesity is posing major challenges for their health care systems. Yet while WHO and other global mandarins mull the options, health care systems like that of Colombia are left to seek on-the-ground solutions.
In a country often defined by poverty and war, where it’s been estimated that at least 10% of the population are undernourished, obesity might seem to be a marginal problem. But in 2010, a national nutrition survey indicated that over a five-year period, there had been a 10% increase in the number of overweight and obese Colombians, including children. Some 25% of children aged 5–17 had excess body mass. In some parts of the country, that tally was as high as 31%, roughly equivalent to childhood obesity rates in the United States, which have been labelled epidemic.
Precise numbers on chronic disease levels in Colombia are difficult to obtain. But the Center of Development Projects at Pontificia Universidad Javeriana in Bogotá, the Colombian capital, estimates that the total burden of chronic disease increased 40% between 1995 and 2005.
Eight of the 10 leading causes of mortality in Colombia are chronic or noncommunicable diseases, according to the Mission of Colombia to the United Nations. In 2002, noncommunicable diseases accounted for 68.1% of 243,747 deaths in Colombia, according to the Pan American Health Organization. Cardiovascular disease was the leading contributor, with age standardized mortality ratio of 239 per 100,000, followed by malignant neoplasms (116 per 100,000), chronic respiratory diseases (54 per 100,000) and diabetes (32 per 100,000).
“While WHO and other global mandarins mull the options, health care systems like that of Colombia are left to seek on-the-ground solutions. “
“It’s a problem that Colombia has to tackle immediately,” says Dr. Luis Fernando Gomez, professor of pathology at the Faculty of Medicine at Pontificia Universidad Javeriana in Bogotá. “The biggest change is what is happening to children: We can’t wait until we have problems on the scale of the U.S.A. and Canada. Obesity was at first concentrated among the wealthiest but we are now on the path where it is also affecting the poorest.”
“A reduction in cholesterol levels, blood pressure and obesity is a priority to control the ongoing epidemic of cardiovascular diseases,” which has been estimated to be the cause of 40% of deaths in Colombia, concurs Dr. Leon Bautista, assistant professor of population health services at the University of Wisconsin in Madison.
Gomez and a consortium of nutritionists pressed the government of Colombia into passing an “anti-obesity law” in 2009 that promotes mass physical exercise and regulates school nutrition and food and beverage marketing. But in the face of resistance from the processed food industry, implementation has been an obstacle, Gomez says. “Although the government passed a very progressive law on this issue, it continues to view health promotion mostly as a matter of personal lifestyle choice. That lets them wash their hands of taking further action.”
As evidence of government inaction, Gomez cites the gradual whittling of road space allocated to Bogotá’s famous “Ciclovia” program, which closes major streets in this city of nine million on Sundays to promote walking and biking. Between 1990 and 2002, the city invested $180 million to create 291 kilometres of dedicated bicycle paths and by 2003, the number of trips made by bicycles, as opposed to other forms of transportation, had increased to 4.4% from 0.058%.
Some 38 cities in 11 countries have followed Bogota’s lead and a study found that the benefits of Ciclovia programs outweigh the costs (J Urban Health 2011 Dec 15 [Epub ahead of print]).
But with automobile ownership exploding in Bogotá, the program was reduced. It’s a retreat that flies in the face of public health, Gomez argues. “As the cities of Colombia and elsewhere in the developing world increasingly mimic the car-oriented settlement patterns of first-world cities, the same kinds of chronic diseases and obesity problems associated with physical inactivity in the United States and other car-based societies will arise.” <>