By Peter Delobelle
On 19-20 September, the UN convened a High-Level Meeting (HLM) on the prevention and control of non-communicable diseases (NCDs), focusing on the four most important diseases – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and their risk factors. The aim of the HLM was to adopt an action-oriented Declaration that would serve to shape national and global agendas in order for the international community to ‘take action against the NCD epidemic, save millions of lives and enhance development initiatives’ (http://www.un.org/en/ga/ncdmeeting2011/). Such action was urgently needed given the increasing threat posed by NCDs to social, economic and human development worldwide. According to WHO, in 2008 about 63% of deaths globally were due to NCD, of which nearly 80 percent occurred in developing countries, contributing to poverty and hunger and thus impacting the achievement of internationally agreed development goals, including the Millennium Development Goals (MDG).
A matter of social justice
The UN first officially and publically outlined the rationale for the HLM in May 2010. In a resolution adopted by the General Assembly, the UN acknowledged the steps leading to the Summit : previous health resolutions, decisions and action plans, including the 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. The resolution also mentioned the importance of targeting risk factors known to affect health, such as the conditions in which people live, their lifestyle and the broader determinants of health, including the Social Determinants of Health (SDOH), and stressed the need for a multisectoral response to combat NCDs. The resolution said that everybody has a right to enjoy the ‘highest attainable standard of physical and mental health,’ and emphasized the developmental objective of global health, in turn requiring concerted efforts at local, national, regional as well as global level, including the need to strengthen international cooperation in the area of public health.
In response to the HLM announcement, organizations developed mission statements and action plans worldwide, asking individuals and concerned groups to sign petitions. Some organizations focused on targeting NCDs as a whole, applying the lessons learnt from the HIV/AIDS epidemic, whereas others sought to bring the focus on lesser known NCDs. Whatever method was used, NCD had been put on the global health agenda and the world was forced to pay attention to the upcoming Summit. The IUHPE, for example, produced a document outlining the role of health promotion in the NCD agenda, with a broad focus on why NCDs are important to target in general, and how health promotion values and approaches are particularly useful in approaching the interaction of the SDOH and NCDs (http://www.iuhpe.org/index.html?page=51&lang=en). IUHPE therefore called for an expanded role for health promotion and advocated coordinated intersectoral actions, resource allocation, and increased investment in the health promotion workforce.
Another major initiative involved the four leading NCD organizations, the International Diabetes Federation, World Heart Federation, Union for International Cancer Control and the International Union Against Tuberculosis and Lung Disease. Together they created an NCD Alliance in order to coordinate the global civil society response, and proposed five priority actions and interventions for responding to the epidemic: tobacco control, salt reduction, improved diets and physical activity, reduction of alcohol intake, and essential drugs and technologies. The International Diabetes Federation moreover put out a call to Action on Diabetes and developed a monthly newsletter that was distributed throughout the year, called Advocacy to Action, aiming at advocating for and mobilizing others in planning for the summit and its aftermath. Local initiatives also abounded, including a meeting at Harvard Medical School in order for the global community to draft a set of recommendations and action plan for the Summit (http://www.pih.org/pages/harvardncd).
At the HLM, hundreds of delegates gathered, including Heads of State and Government, senior ministers, and experts, adopting a Political Declaration which called for national plans to be in place by 2013 in order to curb the risk factors leading to the four groups of NCDs (http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/64/265&Lang=E). The Declaration outlined the commitment of Member States, WHO, civil society and the private sector, but the lack of time-bound global targets, such as a commitment by 2025 to reduce preventable deaths from NCD by 25 percent – a target which WHO believed to be achievable – was criticized and the Declaration dubbed as ‘more a politically correct declaration than a political declaration of war’. Member States, however, committed to a set of important first steps, such as the establishment of national NCD policies by 2013. As the leading health agency, WHO was called to submit ‘options for strengthening and facilitating multisectoral action,’ and to prepare recommendations for voluntary targets to facilitate national action frameworks by the end of 2012.
What are the options?
According to WHO, both individual and population-wide prevention efforts are required to curb the growing NCD epidemic. There are proven highly cost-effective interventions to target NCD, including tobacco control, salt reduction, and combined drug treatment for people at high risk of cardiovascular disease. These interventions together could avert 32 million deaths over 10 years at an annual cost of approximately $6 billion, which is about half of what is needed for the annual cost of drugs for HIV/AIDS. Other interventions include the reduction of dietary saturated and trans–fatty acids and sugar, and some have already been implemented at national levels, based on the commitment to support NCD prevention using effective policy interventions which include legislation, regulation, and taxation. Examples of regulatory strategies include the restriction of food advertisements targeting children and the taxation of unhealthy food, the revenue of which could in turn be used to promote healthy nutrition and anti-obesity programs.
Conflicts of interest, however, clearly arise when implementing the proposed agenda, as explicitly recognized in the Declaration with regard to the fundamental conflict of interest between the tobacco industry and public health. There are also other conflicts of interest with the food, beverage and health care industry. A fat tax is considered paternalistic and critics have pointed out that food taxation is regressive because poor people are the prime consumers of high-fat foods. The question also arises as to which foods should be taxed and why, requiring arbitrary decisions that are less clear-cut than implementing smoking bans in public places, for example. In addition, imposing taxes in and by itself is probably inadequate to produce long-term dietary changes and should be complemented by other measures aimed at promoting healthier lifestyles. School policies on healthy nutrition and changes to the built environment with improved access to healthy food outlets and safe places and recreational facilities for exercising could play a beneficial role in this respect.
Actions undertaken in the European Region are based on the Action Plan of the European Strategy for the Prevention and Control of NCDs (2012-2016), which includes both fiscal policies and marketing controls to reduce the demand for unhealthy products. In the last few years, many European countries also ratified the WHO Framework Convention on Tobacco Control and implemented strong smoke-free policies, while the Regional WHO Office developed an action plan to reduce the harmful use of alcohol for submission to its Regional Committee. Some countries also implemented price changes to target unhealthy diets, including the so-called ‘fat taxation’ in Denmark and Hungary.
Political leadership and advocacy
In order to meet the requirement for a multipronged and multisectoral campaign, as called for by the Declaration, health-in-all policies and whole-of-government approaches need to be considered, and capacity strengthened at all levels of government. This, however, requires political leadership and commitment by all relevant stakeholders, including civil society, academia and, where appropriate, the private sector. In addition, the Declaration encourages the inclusion of NCDs in development cooperation agendas and initiatives, and asks international organizations to provide technical assistance and capacity building for NCDs in developing countries, based on harmonization and alignment with recipient country national priorities. Member States are also encouraged to investigate options for funding, including the development of innovative long-term financing approaches such as a solidarity tobacco contribution which could be based on the gradual increase of national excise taxes in order to supplement the lack of international health development funding.
In order to monitor the progress made with regard to implementation of recommendations and actions outlined by the Declaration, civil society will need to be vigilant and ensure that a comprehensive review and assessment of progress in the prevention and control of NCDs is conducted in 2014. In this regard it will clearly be critical to reaffirm the need to integrate NCDs in future internationally agreed development goals, given the fact that the current MDGs end in 2015 and the current discussions related to a successor framework refer only marginally to NCDs. As an international organization within the field of health promotion, ISECN, and IUHPE in general, should remain closely involved in this debate in order to hold national and international stakeholders accountable for implementing the NCD agenda now and in the future, using a human rights approach based on social justice and equity. Only through continued advocacy and monitoring can this rare opportunity to push the global NCD agenda be exploited in order to save millions of lives worldwide.
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Published: October 2011