The Global "Slow-motion Catastrophe" of Chronic Disease

Last week in Moscow, the World Health Organization and Russian Federation held the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, which addressed the "slow-motion catastrophe" of rising rates of non-communicable illnesses like heart disease and diabetes. WHO Director-General Margaret Chan warned that diabetes rates have skyrocketed in both rich and poor countries, but in poor countries "health services are almost totally unprepared to cope with the onslaught of chronic demands that come with the rise of non-communicable diseases."

As the WHO points out in a discussion presentation (PDF), just four NCDs are responsible for more than 60% of deaths worldwide: cancers, cardiovascular diseases, diabetes, and chronic pulmonary diseases. Tobacco use, harmful use of alcohol, physical inactivity, and poor diet are major risk factors for these conditions. And while developed countries are worried about chronic diseases' contributions to soaring healthcare expenditures, the effects on developing nations are even more severe. The presentation explains:

However it is in developing countries, particularly on the African continent, where the expanding NCD epidemic is fanning poverty, stifl ing economic growth and hindering development. In many households, the bulk of a family's income will go to caring for a loved one ailing from a NCD. Such "catastrophic expenditures" are preventing millions of people of advancing their lives and providing for their children's futures.

The Moscow Declaration that came out of the meeting emphasizes that "prevention and control of NCDs requirs leadership at all levels, and a wide range of multi-level, multi-sectoral measures aimed at the full spectrum of NCD determinants (from individual-level to structural) to create the necessary conditions for leading healthy lives." It includes a commitment to action on a total of 23 steps -- 11 of which are for national governments, six for ministries of health, and six for the international level. The steps include:

At the national level:

Implementing cost-effective policies, such as fiscal policies, regulations and other
measures to reduce common risk factors such as tobacco use, unhealthy diet, physical
inactivity and the harmful use of alcohol;

At the ministry of health level:

According to country-led prioritization, ensuring the scaling-up of effective, evidence-based and cost-effective interventions that demonstrate the potential to treat
individuals with NCDs, protect those at high risk of developing them and reduce risk
across populations.

At the international level:

Examining possible means to continue facilitating the access of low- and middle
income countries to affordable, safe, effective and high quality medicines in this area
consistent with the WHO Model Lists of Essential Medicines, based on needs and
resource assessments, including by implementing the WHO Global Strategy and Plan
of Action on Public Health, Innovation and Intellectual Property.

Although the WHO stresses that low-cost solutions to the NCD epidemic exist, it's hard not feel daunted by the scale of the challenge. Jake Marcus of the Institute for Health Metrics and Evaluation has a great piece in The New Republic considering why there's no global movement to combat NCDs, and he compares the fight against chronic illnesses to the global campaign against HIV/AIDS. NCDs, he point out, will be harder to organize around than AIDS because they build up over many years and have far more than one pathway for transmission; tend to take their most visible toll on older people, who are less likely to spark emotional responses from potential donors; and don't create the fear that a higher rate of infection increases everyone's chance of contracting the disease.

I'll add another challenge to his list: HIV doesn't have a manufacturer that benefits when people engage in risky behaviors, but their are plenty of companies that benefit from the unhealthy lifestyles that increase the risk of NCDs. Tobacco companies will collapse if everyone stops smoking. Alcohol companies will see their profits drop if excessive drinking stops. The manufacturers of high-calorie/low-nutrient food stand to lose millions if people adopt healthier eating habits. Carmakers could see their markets shrink as local governments make it easier for people to get around by walking, biking, and riding public transportation.

One of the national-level steps in the Moscow declaration is "Engaging the private sector in order to strengthen its contribution to NCD prevention and control according to international and national NCD priorities." The Washington Post's Will Englund reported from Moscow that "Unhealthy food, and what to do about it, was the most sensitive topic at the gathering." He notes that 10 big producers have formed "an alliance that says it is committed to reducing salt, sugar and fat in processed food and restricting advertising aimed at children. And he provides a couple of examples from countries that have addressed the issue of salt:

Finland tried to reduce the amount of salt in food by seeking voluntary commitments from manufacturers, with mild success, said Sirpa Sarlio-Lahteenkorva, an official in the Finnish Health Ministry. But when the government required salt labeling, consumption dropped sharply, she said. The same happened when the government increased taxes on alcohol. (Finland is the world leader in reducing deaths from non-communicable disease.)

The government of Argentina leaned on the country's bakeries and, without resorting to formal measures, got them to reduce by nearly one-third the amount of salt in bread over a few months, said C. James Hospedales, coordinator for chronic disease at the Pan American Health Organization.

I hope the Moscow meeting generates some additional funding and high-level attention to the problem of non-communicable diseases, because it's going to take a lot of work to reduce the global risk.