Last week, the World Health Organization (WHO) held its annual World Health Assembly (#WHA65) in Geneva, Switzerland. I was particularly interested to read the outcomes of the session on the prevention and control of non-communicable diseases (NCDs) – cardiovascular disease (CVD), cancers, chronic respiratory diseases (eg asthma and chronic obstructive pulmonary disease [COPD]) and diabetes mellitus (especially type 2 diabetes [T2DM] – which took place on 22nd May 2012. Most medical writers will work on one or more of these conditions at some point during their career because of their high prevalence and their correspondingly high levels of interest to the pharmaceutical and medical devices industries.
The background to the session is interesting.
In 2009, the leaders of the International Diabetes Foundation (IDF), World Heart Federation and the International Union Against Cancer (UICC) came together at WHO’s 62nd World Health Assembly to launch a campaign for a UN summit on NCDs to address the demographic-shifting levels of deaths from NCDs in low- and middle-income countries.1 This group highlighted the futility of spending millions of dollars every year to save people from infectious diseases only to lose them at a relatively early age to NCDs, particularly when efficacious drugs to address these conditions are readily available and cheap. In 2010, this group of three founded the NCD Alliance (www.ncdalliance.org), bringing together a network of 880 member organisations in 170 countries to continue to advocate for action against NCDs.
The UN duly held a high level Global Assembly Meeting in September 2011, to which >30 heads of state and government and ≥100 other senior ministers and experts were invited and which upheld the NCD Alliance’s call for NCDs to be added to the development agenda. As a result, the UN charged WHO with setting up a global surveillance programme and making recommendations for voluntary global targets for reducing deaths due to NCDs before the end of 2012.2 Perhaps surprisingly (and underlining the seriousness with which the UN regards these goals), this is only the second health-related campaign promoted by the UN – the first being the campaign to control the spread of HIV/AIDS.
The statistics3 that prompted the UN to act are shocking. NCDs account for 57 million deaths annually (63% of all deaths). Approximately 16% of all deaths due to NCDs occur in the under-60s. A disproportionate number of these occur in developing nations, where widespread death and debilitation among adults of working age could retard industrial development and where in any case the loss of a wage earner throws families back into poverty from where they are more susceptible to the effects of NCDs. Worse, WHO estimates that the proportion of deaths attributable to NCDs will increase by 17% worldwide in the next decade. The key messages to take from this are that NCDs are not conditions only associated with the developed world and not only associated with aging.
The burden of caring for people with NCDs is no less daunting. One in three people has raised blood pressure (a risk factor for CVD), rising to almost one in two in Africa, and one in ten people has diabetes mellitus.4 Moreover, in every region of the world the prevalence of obesity – which is a risk factor in T2DM, CVD and some cancers – doubled between 1980 and 2008.3 Today, half a billion people (12% of the world’s population) are considered obese. Worryingly, it is thought that there are hundreds of millions of people worldwide who are unaware that they have a NCD and whose first contact with the health service will only come when they develop complications associated with advanced disease. No wonder, then, that Margaret Chan – Director-General of WHO – referred to NCDs as ‘the diseases that break the bank’ at last week’s meeting.
It is generally recognised that the slowly progressive nature of most NCDs requires a quite different mindset at government/NGO level to that necessary for promoting control of infectious disease outbreaks. The NCD programme must be goal orientated and focussed on prevention (ie reducing exposure to risk factors such as tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and universal access to treatment.1 WHO has announced its aim to work with its existing stakeholders in the education, agriculture, sports, transport, communications, urban planning, industry, employment and finance sectors, in addition to the health sector, to develop a global framework for the prevention and control of NCDs.5
De Maeseneer et al, in their commentary on the aims of the NCD Alliance, agree that a fundamentally different approach is required for preventing and controlling NCDs but disagree that the vertical, disease-orientated approach advocated by the Alliance is the best way to approach the problem.6 They note that altering patient perceptions and behaviours are key aims in preventing and treating NCDs and that this process requires more than just access to medicines. They believe that it is necessary to empower patients, reduce barriers to healthy lifestyles and care that reflects the needs of individual patients and that this is best achieved by global investment in local primary healthcare.
And the outcome of the session at the WHA65? A target to reduce premature deaths due to NCDs by 25% by 2025 – this is a massive target (and an incredible achievement for the NCD Alliance).
Speaking personally, though, I was struck by the lack of any reference to the need for innovation in the approach to the prevention and control of NCDs. We know what the causes are, we know how to prevent NCDs and, as the Alliance has pointed out, medicines are available – but still their prevalence is increasing in countries with well-funded healthcare services and in countries without.
De Maeseneer et al, whose paper was published before WHO assembly, say that: ‘We must fundamentally rethink the way that we address complexity in health problems, in both developed and developing countries.’ And I agree with them.
1. IDF, UICC, International Heart Federation. Time to act: The global emergency of non-communicable diseases (2009). Available at: http://www.world-heart-federation.org/fileadmin/user_upload/documents/Publications/Time%20to%20Act%20-%20High%20Res.pdf
2. UN News Center. UN launches global campaign to curb death toll from non-communicable diseases (19 September 2011). Available at: http://www.un.org/apps/news/story.asp?NewsID=39600&Cr=non+communicable+diseases
3. World Health Organization. World health statistics 2010 (2011). Available at: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf
4. World Health Organization. World health statistics 2012 (May 2012). Available at: http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Brochure.pdf
5. World Health Organization. Sixty-fifth World Health Assembly: daily notes on proceedings. (Tuesday 22nd May, 2012). Available at: http://www.who.int/mediacentre/events/2012/wha65/journal/en/index4.html
6. De Maeseneer J, Roberts RG, Demarzo M et al. Tackling NCDs: a different approach is needed. Lancet 2012;379:1860–1. (Free registration.)