Defining Noncommunicable Diseases
Eli Y. Adashi, MD: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One-on-One. Joining me today is Dr. Téa Collins, Executive Director of The Non-Communicable Diseases (NCD) Alliance, a Geneva-based advocacy organization, and expert in the practice and policy of global health. Dr. Collins joins the alliance at a critical time in its relatively brief history. Welcome.
Téa Collins, MD, MPH, MPA, DrPH: Thank you.
Dr. Adashi: Perhaps in the best interest of our viewers we could start by defining what comes under the heading of noncommunicable diseases, and then we could go from there.
Dr. Collins: Definitely. I think the title is somewhat unfortunate because with something that's called "non" it already means that it's not really very important. "Noncommunicable disease" is a relatively new term; we used to call them chronic conditions and chronic diseases, and I think physicians are still more used to this term. The reason we say "noncommunicable disease" in global health right now is because some of the communicable conditions became chronic, such as HIV/AIDS and tuberculosis. So to distinguish and differentiate somewhat, we say that these conditions are not communicable when we're talking about cancer, diabetes, or some chronic respiratory infections or cardiovascular diseases. We thought a lot about whether we wanted to continue calling them noncommunicable diseases and exactly because of this reason -- that it's "non" -- the consensus now is to just say noncommunicable diseases.
Dr. Adashi: So it would seem that even if imperfect, the term has stuck by now.
Dr. Collins: Definitely.
What Are the Common Risk Factors?
Dr. Adashi: Everybody is using it and so it's too late to go back. Is there a common thread that nevertheless in some way unifies this seemingly disparate group of conditions you mentioned -- heart disease, lung disease, cancer? Are there elements that undergird, if you will, all of those in some way?
Dr. Collins: The reason we group them together (again, in public health; probably from a medical perspective we wouldn't necessarily put them in the same category) is that they do have common risk factors that are easily modifiable with lifestyle changes -- for example, tobacco control, reduced alcohol consumption, healthy diets, and exercise. When we do this, we pretty much prevent all 4, which is a convenient catch-all. But in real life it doesn't work this way.
Another reason these 4 conditions are grouped together is that there was a World Health Organization (WHO) report in 2005, so this name basically comes from the WHO. When they looked at the burden of corporal disease, they realized that almost 60% of all deaths are caused by these 4 conditions, and 80% of these deaths are happening in lower- and middle-income countries. We realized that these 4 diseases are really responsible for the global disease burden, and it made sense from the public health perspective to address them as a group.
Top Causes of Preventable Death
Dr. Adashi: Is it accurate to say that more people die of noncommunicable diseases than of the conventional communicable diseases?
Dr. Collins: Probably, because these diseases are responsible for two thirds of deaths. Some people say, incorrectly, that you have to die from something and that actually it's a good thing if you die from these conditions because they're diseases of aging -- which is not correct. The most recent evidence suggests that what we fear is the premature preventive deaths. These are the conditions that affect young and old alike. They affect the rich and poor. This is why it's really a global emergency and hence the high-level meeting.
It is a challenge, and it's not only a medical challenge but also a developmental challenge. We still need to convince some skeptics that it is a developmental challenge because it has some economic consequences. We know that poor people suffer disproportionately, and not only in developing countries but also in rich countries. People who don't have access to healthcare, people who don't have good lifestyles, who cannot afford medicine or healthy food, suffer disproportionately. This is why we say that it is a developmental challenge and why we have the high-level meeting, which is a meeting for the heads of state. It's for governments, because a global emergency really requires a global response.
The Economic Impact of Noncommunicable Diseases
Dr. Adashi: We mentioned that over 60% of global deaths are attributable to noncommunicable diseases. Have there been quantitative or semi-quantitative estimates of the economic impact of these diseases now and going forward towards 2030, maybe 2050?
Dr. Collins: Definitely. There were some attempts in the past, and most recently there were 2 studies. The World Economic Forum just launched their new reports a couple of days ago at the General Assembly, the Summit meeting. There are 2 studies that are 2 sides of the same coin. The world economic study (or the economic forum study) was conducted in collaboration with Harvard School of Public Health, and they estimated the cost of inaction. What's going to happen if we continue the same way? Of course we are doing something about chronic conditions and noncommunicable diseases, but it is not enough. It's a billion or so dollars lost due to economic productivity, which is obvious. Then there is the WHO study, which estimates cost of action. What is going to happen if we scale off the interventions to address these conditions?
There are 2 kinds of interventions:population-wide, which is public health measures, and they're as simple as tobacco control, alcohol control, healthy diet, and physical exercise; and then there are individual-level interventions that, for physicians, translate basically as medical care, from general counseling to giving multidrug therapy to patients who are at high risk of developing cardiovascular conditions. The cost is really minimal. I haven't had a chance to really study these reports, but off the top of my head I can give you some numbers: Cost of individual interventions ranges between $1 and $3 per capita. And then cost of inaction is around $25-$75 per capita. There is a significant difference. It really pays off from the economic perspective to do something rather than just wait and see what happens.
Dr. Adashi: And it helps to know that the amounts involved are not ...
Dr. Collins: They're not huge.
Dr. Adashi: That it would be impractical in the face of some of the economic challenges that the world faces and the various donor countries face.
Dr. Collins: Definitely.
Dr. Adashi: The more manageable the costs are, of course, the better the outlook for action, it would seem.
Dr. Collins: I just wanted to add that we all understand that due to financial crisis -- and there is some donor fatigue as well -- there is less investment in health. But every government has some health budget, and it's really important for member states to realize that it's important how we prioritize where we put our money. What you need to really know is the epidemiologic situation in your country and decide whether this burden of disease is really big. Then you really need to put more money in, let's say, noncommunicable diseases or some other program. But it doesn't mean that the programs have to compete. It's just important to know where your priorities are.
The NCD Alliance and United Nations Summit on Non-communicable Diseases
Dr. Adashi: The organization that you head is about 2 or 3 years old. And yet it has had a remarkable effect on the process that led to the high-level meeting, which is transpiring as we speak. Tell us a little bit about how you did it and what's in store for the organization now that the meeting is transpiring and hopefully is producing some results, which we can discuss a little bit later.
Dr. Collins: The NCD Alliance is a really young organization. It started in 2009. There are 4 major disease-specific organizations. They areglobal federations: the International Diabetes Federation, Union for International Cancer Control, the International Union Against Tuberculosis and Lung Disease, and the World Heart Federation. So these federations represent the 4 diseases that we are talking about. And they realized that they were much stronger together to address the NCD challenge. It was remarkable cooperation when these 4 federations got together and formed the NCD Alliance in 2009. Initially they operated somewhat informally and their major requests were basically 4 main acts, as they're called. First of all, they wanted the summit. They realized that this is basically the second health summit after 2001 (the first one was on HIV/AIDS), and we know that after that there was a whole change in the global health landscape. So the first request was that they wanted the global summit to really put the issue on the global agenda. The second one was simply putting noncommunicable diseases into Millennium Development Goals, because we know that Millennium Development Goals do not have a target on noncommunicable diseases. They just refer to controlling malaria, tuberculosis, and other diseases.
Dr. Adashi: Should we consider that an oversight at the time, or unawareness, perhaps?
Dr. Collins: I guess it wasn't perceived as an emergency. Noncommunicable diseases, other than being noncommunicable, are also chronic, and people do not perceive it as an acute emergency, especially at this level. The United Nations (UN) at this highest level didn't perceive it as a challenge to development until recently. There was another act, which was access to medicines; they have to be affordable and available to everyone. The fourth one was health systems. Relatively recently, in January, we recruited a team, an NCD Alliance team; it's very, very young -- only 9 months old. We started operating more formally, and we were joined by partners who are also like-minded. There are no governmental organizations devoted to the cause, and we have about 10 partners who are all over the world, mainly in the United States and in Western Europe.
But it has been really remarkable because now we are represented by 2000 organizations in over 170 countries. It is a pretty big group of organizations that represent the voice of civil society. We are also working with our common interest group of about 400 organizations all over the world. Some of them are in-house; some of them are in health-related fields but with a very strong interest in noncommunicable diseases. This is how we came to be, and the summit project was the main thing -- the summit campaign, of course.
I would also like to mention that we do some technical work as well, because we need some evidence to support our advocacy. Advocacy matters are getting increasingly sophisticated. We do need to be a research base, and we need to have arguments that politicians understand. We have working groups and some medical professionals particularly interested in that. We have working groups of people from academia and other civil society organizations that are working in the field. I want to name a few:Harvard School of Public Health, Management Sciences of Health, and other health organizations working with children. This is one of the issues that does not really come to your mind when you're talking about noncommunicable diseases -- that children are affected too. There are congenital malformations, there is rheumatic heart disease, there is asthma -- a myriad of problems. There are working groups that are producing papers, addressing different issues, and showing the multidimensional character of noncommunicable diseases. Because you have to really reframe the issue to start thinking about it differently, rather than just in regard to aging and escalating health system costs. It has been really remarkable to work with basically everybody in academia. We have private-sector supporters with all these different perspectives who are working on the same issue. We also understand that to really address noncommunicable disease, we need everybody on board, starting with patients and ending with health systems, medical professionals, private sector, and industry. You name it, it's everybody's business.
Negotiating a Political Declaration on Noncommunicable Diseases
Dr. Adashi: By all accounts, what will happen going forward will, to a large degree or in part, be determined by the outcome of the high-level meeting or the summit, and specifically the political declaration that is deliverable of such meetings. As we speak, has the political declaration been finalized? Or is it no longer in draft form? Has it been ratified or is that still to transpire?
Dr. Collins: That is a great question. I am pleased to announce that it has been adopted. It was adopted yesterday. It's already there; it is not a draft anymore. It was a nice surprise in a way because, normally, political declarations get adopted after the meeting is over. But yesterday after the meeting, it was announced that if there were no objections and countries were all for it, then it would be adopted the way it stood at that time. I think it is great news. I also think it is important to adjust our expectations somewhat, because the political declaration is by no means legally binding. It is politically binding because governments committed to it and negotiations were really tough.
I need to explain how this works. Member states basically negotiate whatever goes into the political declaration and they negotiated it in groups. So it does represent a global commitment to action. It's a very good and strong document. It's not perfect, but hopefully now it's time for member states to start implementing the commitments they made.
Recognizing the Magnitude of the Problem
Dr. Adashi: What about the document do you find is strong and helpful in keeping with your aspirations and expectations?
Dr. Collins: It is stronger in the sense that it really recognizes the magnitude of the problem. Even the use of the word epidemic -- we really fought hard for that. Civil society was pushing hard to make sure that this stayed in the declaration; it got dropped several times. It's just funny how every word means something and every word got there because somebody fought for it, whether it's the government or nongovernment organizations. It was a really collective effort, to some degree. I just don't want to mislead our audience that we didn't negotiate clearly. It's all up to member states. They are the ones who negotiate. But clearly civil society is engaged and is trying to influence a country delegation or their countries on the ground. This is how we work. We work through our member organizations who work with their governments, and we were also trying to pass along our objections or support when the negotiation process took place. We also worked with the missions to the UN in New York and tried to educate them and just to pass along the civil society's requirements. It was a very tough but also enjoyable process. I think that the summit is now somewhat a celebration because the declaration has been adopted, but now it's time for action. The most interesting time is just the beginning.
Where Does the NCD Declaration Fall Short?
Dr. Adashi: Are there elements of the declaration that fall short of your expectations and hopes for the summit?
Dr. Collins: One of the main things that I would like to mention is the targets. Again, if we make comparison with the AIDS declaration of 10 years ago, the political document had really well-quantified targets and commitments. It was more binding and a little more clear that it was going to happen in the near future. Right now, this political declaration calls for these targets and urges governments to develop them. There is more to come. But there are no numbers. There are no global commitments to reduce mortality by 20% by 2025.
Dr. Adashi: So, unlike the Millennium Development Goals, for example, there are no measurable endpoints.
Dr. Collins: It's not there. It has been somewhat disappointing. But it's also understandable because countries did not want to rush and commit to something that maybe they wouldn't be able to implement. It is also important to differentiate between global targets and indicators. National targets are more doable than local targets. This still has to be worked out. Another somewhat weak point is partnerships. The NCD Alliance was pushing hard to make sure that some kind of partnership would be formed that would involve the UN, nongovernment organizations, and the private sector, where we all come together as a monitoring body and just make sure that commitments are being implemented and also offer some solutions.
Dr. Adashi: For which there is precedence in other areas.
Dr. Collins: Definitely. In terms of multiaction, the political declaration calls on the WHO to consider options to how this partnership is going to look and submit this proposal to the General Assembly in May 2012. There is hope and we have some window of opportunity there to work hard and make sure that everybody's on board. By "everybody," I mean governments, known governmental organizations, academia, and the private sector. I think it is critical that the private sector gets engaged because they are part of the solution.
The Involvement of Heads of State
Dr. Adashi: Among other things, the weight of the impact of a high-level meeting is judged by the presence or absence of heads of state. When it was all said and done, how many heads of state ended up attending the high-level meeting?
Dr. Collins: I guess that remains to be seen. We will get more accurate information after this summit is over, 2 days to closing. Right now, we know that there are at least 34 heads of state and pretty much every minister of health from every country. I attended a roundtable (I am just coming from that meeting) on international cooperation. It was remarkable because member states are making statements and pretty much every statement was made by ministers of health. It is a very good sign that the ministers of health are engaged. But again, I need to emphasize that it's a developmental meeting. It is a high-level meeting. It is for heads of state and we do want the commitment at the highest level. Thirty-four present is not bad. We were hoping that maybe the President of the United States would be interested in attending, but I guess it was not possible. But it is also important to set the example, and member states are also watching each other and seeing who is really committed. But I think 34 is a good number so far.
What Are the NCD Milestones Over the Next 5 Years?
Dr. Adashi: Thirty-four heads of state, 193 member nations, and a substantial number of health ministers really making up the difference. Briefly, before we close, how do you see the next 5 years unfold in terms of the noncommunicable diseases? What's the timeline? What are the milestones that we ought to be looking for? What are the actions that you would hope to transpire in the next 5 years?
Dr. Collins: We have to differentiate between global and national levels because action is required by both. Again, every actor has to do his homework. At the UN level, as I mentioned already, it's really critical to work on targets, which is right now the WHO's job. They have to develop some global targets and submit them to the General Assembly by May 2012. At the same time, at the UN level we are still hoping that they would consider including noncommunicable diseases in the Millennium Development Goals, which may be too late now, because they expire in 2015. But definitely there will be some other goals. I do not know what they will be called yet, and it's really important to have noncommunicable diseases at this level. This commitment will be important.
Dr. Adashi: So that would be correcting the oversight?
Dr. Collins: The action will really be at the national level. Member states have to implement that. This is not to say that globally we are not doing anything on noncommunicable diseases. Clearly, when patients get sick, they have to go to the clinic and get some kind of care. It is really important that there are more resources. First of all, there are no commitments right now to have some additional money flowing in noncommunicable diseases, but integration and coordination are the keys at the primary healthcare level.
We know that we can easily integrate noncommunicable diseases with infectious diseases, especially in low-income countries. You can train physicians differently so they can recognize and address this issue. You can strengthen health systems. There are lots of things that can be done to improve the overall outcome. But more important is involving all the sectors -- not only the health sectors, but food and beverage, agriculture, transportation, finance -- because noncommunicable diseases are really something that everybody can do something about. I think it is time to roll up our sleeves and get down to business, and from time to time we should step back and see where we are.
Dr. Adashi: It would seem that the good news is that there are numerous cost-effective interventions, including integration of noncommunicable diseases with communicable diseases and many others that you mentioned that should allow us to witness some progress in the years to come.
In closing and on a more personal note, if I may, I could not help but note that you are a global citizen, born in the country of Georgia; educated largely but perhaps not exclusively in the United States; and currently living in Geneva.
Dr. Collins: That is true.
Dr. Adashi: Could you fill in the blanks for us?
Dr. Collins: I guess I go where my life takes me. I don't see any limits. I think people are the same everywhere, and where your opportunity takes you and where you can contribute most, I think you need to go there. Of course I am Georgian; it is my native country and I love it very much, but it has its problems. Clearly, noncommunicable diseases are a huge issue. But I think it is more of a cultural thing there too. This is one thing that we do not talk much about. When people are so overwhelmed with other problems, they think that health is not really a priority. This is one of the issues. But I love the United States. This is my second country. I just love the US culture. It is so embracing and forward-looking and energizing. This is somewhere I really love being and I also love being among American people. Geneva, I think, is the humanitarian capital; there is a lot of action: the WHO is there and the NCD Alliance is there. We feel that we are contributing a lot to this global fight against noncommunicable diseases right now. But my commitment is to global health, and I am willing to go anywhere where I can contribute significantly and do something about it so that we can really improve health and make people not only healthier but happier.
Dr. Adashi: Sincere thanks to Dr. Collins and to you, our viewers, for joining Medscape One-on-One. Until next time, I am Eli Adashi.