The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion, Boston/USA

Written by Emily Fisher and Amy Blaisdell

In preparation for the upcoming 2011 UN Summit, multiple organizations partnered together to create an action statement during the meetings on March 2-3, 2011. This movement would hopefully compel the UN to incorporate the issue of Non-Communicable Diseases (NCDs) among those living in poverty in the world agenda. NCDs are diseases which are not contagious and are often caused by biological, environmental, or lifestyle factors. There is a wide range of these diseases- cardiovascular diseases, diabetes, cancer and asthma are all included in this list- that greatly impact mortality and daily quality of life. As one speaker pointed out, we are stuck in limited models that say that the rich die of NCDs and the poor die of Communicable Diseases, but now unfortunately, “problems only of the poor are now not the only problems of the poor.” Aside from this fact, NCDs also currently receive only a small percentage of overall aid. Unlike communicable diseases like AIDS and TB, their cause is not as easy to identify and usually the result of many influences. Therefore there is a feeling of, will the aid make a difference and how will we know? This is an all too well-known dilemma in health promotion, and maybe we can help.

Emphasized over the two days was the importance of partnerships, having vocal advocates and compelling arguments, and integrating healthcare systems. As in the views of our fellow health promoters, the philosophy is that we are not in a zero-sum world.  Although we often do, we cannot continue to dichotomize health care by pitting one value against the other: Prevention vs. Treatment, Infectious disease vs. NCDs, Social Determinants of Health vs. Health Systems Services, Vertical vs. Horizontal programs, Primary vs. Specialized Care. There was also an overall discussion of “diagonal” health care, challenging the traditional approach to health laid out in the Declaration of Alma Atta, which starts with primary care and then works upwards to secondary and specialized care. Diagonal health argues for flexibility and best use of resources to treat, especially acknowledging the future role mobile healthcare may play. With an overall feel of questioning the status quo, health promotion seems well positioned to step up, to raise its profile in the fight against NCD.

The conference was an engaging mix of keynote speakers, researchers from a variety of contexts, and individuals on the ground in these bottom billion nations. Panel sessions with patients and healthcare workers illustrated the power of personal stories in inspiring the audience of who they are fighting for. If this is effective in engaging teams of researchers, clinicians, and academics, how can this not be an effective tool in the larger world context? Even with the different presentations focused on new and sometimes unheard of NCDs, the point was reiterated over and over: this is not a time to compete for action among NCDs, but the time to join together for systematic change. We should focus not on these individual diseases but instead on a health systems strengthening.

“It’s not that we don’t have the strategies… it’s that we don’t have the resources we need to implement these strategies in the locations we’re studying.”    

Paul Farmer

Because the number of small and private aid donors is growing, collaboration among stakeholders is more important than ever, especially in the case of NCDs where interventions need to be long term relative to communicable disease. Treating heart disease, for example, is not possible with a simple course of injections or pills. The creation of a sense of social responsibility of NCDs among the public was encouraged to leverage this growing source of aid. Why should the public care about NCDs of the bottom billion and how can we instill this care in them?

The conference concluded with a document to call for multiple government and state officials to attend the United Nations summit on NCD in September. Even though “health promotion” was not explicitly mentioned, the underlying principles were there. Multiple times it was stated donors must allow LDCs to decide how to use aid, not to be told. Research and evidence for cost efficient interventions was also called for. In the months leading up to the UN summit in September, the climate will be hot for health promotion evidence. We urge each of you to contribute in any way you can, whether it is by contacting your local officials and urging them to attend, spreading the word of effective health promotion interventions as they relate to NCDs, or joining the online discussion continued after the conference: . Conference website: .

Perspectives from two conference attendees: Emily had the opportunity to catch a few live sessions in Boston and Amy took advantage from Bergen through the online-live feed. Sometime in the near future Partners in Health have promised to post the videos from the conference. In the meantime, download the free PDF: The PIH Guide to Chronic Care Integration for Endemic Non-Communicable Diseases. The Guide is based on the experiences and collaboration between Rwandan and international specialists over four years and is written for those designing a health system for care of NCDs in very low-income populations.

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