The Zero Document on Noncommunicable Diseases: It's Not Nothing

Carol Peckham; Richard G. Roberts, MD, JD


November 29, 2012

Editor's Note:
In October 2012, the World Health Organization (WHO) published their zero draft on prevention and control of noncommunicable diseases (NCDs). This is the first document to emerge from the United Nations (UN) High-Level Meeting (summit) held in September 2011 to focus on NCDs. The goal is to increase efforts and resources to meet the rising global challenge of chronic diseases, notably diabetes, cancer, and cardiovascular and pulmonary diseases. Medscape interviewed Richard G. Roberts, MD, JD, former President of the American Academy of Family Physicians Foundation and President of the World Organization of Family Doctors (WONCA). Dr. Roberts emphasized the importance of primary care in this effort and not neglecting the horizontal field while pursing the improvement of vertical specialized areas of disease.

Richard G. Roberts, MD, JD

Medscape: I'm interested in your views on the WHO zero draft on prevention and control of NCDs, which was issued in October of this year.[1] But first, could you give us some background on the NCD efforts?

Dr. Roberts: I'm happy to do that. I've been deeply involved in it. Here's a brief thumbnail of my understanding of where this came from and where it is going. Historically, WHO has focused on infectious diseases using a public health model. However, these diseases are not the world’s major health problem anymore. About 5 years ago, chronic disease became the number one cause of mortality in the world, including in developing countries, where more people are dying of those conditions than in underdeveloped countries. There has been great interest, especially in the Caribbean Community countries, in a greater focus on NCDs, which is WHO's way of saying chronic disease. The big 4 are cardiovascular disease, respiratory disease, cancer, and diabetes. Diabetes has become highly prevalent in the Caribbean region with devastating effects.

Sir George Alleyne, Director Emeritus of the Pan American Health Organization, led the charge to look at this issue and, along with others, began in 2010 the process to have NCDs considered by the UN at a summit. The sequence of events took place over 2 years with meetings of health ministers to shape what that high-level summit would look like. I should emphasize that there has been only one other time in the 60-year history of the UN when a health issue has been the subject of a high-level meeting, and that was HIV/AIDS in 2001. The hope, or perhaps fantasy, of the chronic disease community was that they would have the same kind of support, with billions of dollars annually for research and care, as had come out of the HIV/AIDS summit. So, that was the setting of the stage.

Medscape: Could you describe the NCD Alliance and how they fit in?

Dr. Roberts: The NCD Alliance was formed around that time, by 4 drivers: the International Diabetes Federation, the Union for International Cancer Control, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease, which represented the 4 disease groups. The Alliance did some very smart things. First, they gathered nearly 1000 national organizations, such as the Nigerian Heart Association and the Taiwanese Diabetes Federation, that were focused on these 4 NCDs. The Alliance also approached industry for funding, which would benefit from the initiative, because screening and early detection for these conditions meant early and aggressive interventions and medical treatments. So, the cynic might say that this initiative for some was less about health and more about revenue.

Medscape: How did you get involved with this initiative?

Dr. Roberts: I became involved because the Alliance understood the importance of family medicine and primary care. Around the world, most of the care for these conditions is provided by family doctors, who collectively see way more diabetes than diabetologists do, way more heart disease than cardiologists do, and so on. That's true of every country, even the United States. The Alliance was very kind to WONCA, which did not have the $100,000 required to be a member of the inner circle. I was allowed, however, to listen into their monthly meetings. There was a group of maybe 40 or 50 organizations that listened in to see what the next steps were going to be.

The Alliance embarked on what I thought was a very slick campaign. For example, cancer patients were flown in from a country to meet with that country's UN delegation in New York to talk about how important it was to have better funding of cancer treatment and research and to approve the NCD resolution that was going to be put before the UN.

Medscape: What were the next steps taken by the UN?

Dr. Roberts: The UN process for this issue included an informal hearing at UN headquarters in June 2011. The hearing was to provide nongovernmental groups, such as professional societies and disease-specific associations, the opportunity to present information on this issue. Only about 20 people were invited to talk, and I was one of them.

Most of the presentations at the hearing focused on a specific disease. During my remarks, I emphasized that a few key things were missing there. First, they needed to have a lot more background and information on primary care to understand better how to affect these conditions. Second, they didn't have sufficient representation of the patients' point of view. Finally, there was almost no mention made of mental and behavioral health, and there's no way to change the outcomes for these conditions without addressing that.

So over the following summer, the NCD Alliance and others ramped up an intensive campaign, with everything from coffee mugs to T-shirts, touting the benefits of saving the world by investing in these conditions. It included, as I said before, flying in people from around the world with the condition of interest.

Then, in September 2011, the UN high-level summit on NCDs was held, where it was hoped that many heads of state would attend. However, although a number of health ministers and ambassadors that represented UN member countries attended, there were very few heads of state.

Medscape: Were you able to bring primary care to the front at the September summit?

Dr. Roberts: WONCA had no money and couldn't fly in people. Our total staff is 2 people, but somehow we needed to influence this meeting. In July, I had dinner with a long-time friend originally from Argentina who is on the faculty at Duke University. We discussed the NCD resolution, and I described the challenges in having the views of primary care, patients, and mental and behavioral health better addressed. She mentioned that she had a childhood friend who was part of the Argentine delegation. It turned out that this friend was writing the position paper on this whole initiative for the G77 countries, and Argentina was taking the lead. We pointed out to him some of the problems with the initial draft of the NCD resolution. We were also able to persuade him to place our mutual friend, who has dual US-Argentine citizenship, on the Argentine delegation for the high-level meeting. The final resolution was much better balanced thanks to the efforts of my Argentine friends.

Medscape: Could you describe what the zero document is?

Dr. Roberts: WHO divides the world into 6 regions. Each region was given the NCD resolution passed by the UN and directed to develop an action plan for implementation of the resolution goals, in consultation with the member organizations (countries) within their region. Next, they'll be getting feedback from around the world and, we hope, will refine it so that a global action plan will emerge, and then it will be customized for the regions. Then the regions will be measured against the plan over the next 3-5 years. For me, it was a good learning experience on international diplomacy and politics, and I felt like primary care came away from this having had some input on the process. I was happy that we could, if not stop the train, at least change its directions a little bit.

Medscape: What are you objections to the zero document?

Dr. Robert: The zero document is not unreasonable. Their principles and objectives are fine, but our biggest concern with this whole initiative was taking a purely vertical approach with these 4 conditions. For instance, why are those 4 more important than depression or osteoarthritis? Why do they want to borrow more money for these areas without regard to the effect on the rest of the health system? Let me give you an example that may surprise you.

Who can be against HIV/AIDS funding? It's a terrible disease, and millions have died. However, when I was in South Africa, I met a family doc who was induced to quit his position as a district doctor to focus on HIV/AIDS. The way they induced him to make this change was to pay him substantially more than he was earning as a family physician in the district. And what happened in his community was that even as HIV/AIDS mortality rates went down, the overall mortality rate went up due to events like kids dying of diarrheal disease and old people dying of pneumonia, conditions that could have either been prevented or treated early on by this doctor. So, our concern as primary care physicians is that when you push on one part of the balloon, another part bulges up. If you take only a vertical focus, such on HIV/AIDS, by definition, you're ignoring the horizontal issues. What then can the health system infrastructure really provide?

Here is another example. A common belief is that we're about to cure polio. We're going to make it extinct. I was in Tajikistan last year where there was a rising incidence of polio. I asked one of the doctors, who had 2 babies newly diagnosed with polio, if he immunized his babies. He responded, "Of course, but we get the vaccine from the government, which sometimes buys it at a discount on the black market and the vaccine must be refrigerated, but we have electricity only a few hours a day for a few months of the year." Don't get me wrong. Polio vaccine represents a huge milestone in public health. I share the belief -- and hope -- that polio will someday be extinct. Yet, if we think of the vaccine as the magic bullet and do not take account of the many other factors that affect health outcomes, we will be disappointed.

Medscape: I hear people say "25 by 25" in association with this initiative. I also have heard "15 by 15." What do these numbers mean?

Dr. Roberts: The 25 by 25 was part of the UN resolution, which aims for a 25% reduction in death by the year 2025 for these 4 chronic conditions. The "15 by 15" is a global primary care initiative started about 4 years ago, whose objective is that, by 2015, those who fund healthcare and research for target diseases (vertical programs) should dedicate 15% of those funds to support the primary care infrastructure (horizontal programs). So, for instance, if you want to study cardiovascular disease in Lesotho, use 15% of the funds to study that problem at the primary care level. We want to be sure that whatever is done vertically connects horizontally with what's on the ground. The WHO and UN parlance for this is "health system strengthening."

So far, this has been only a conceptual idea. Unfortunately, in the United States, not many primary care physicians serve on study sections for the National Institutes of Health, sit on the boards of health plans, and so on. Therefore, I don't know how much traction the 15-by-15 concept will get in the United States. In Europe, where primary care is much more valued and, in fact, is fundamental to the entire health system, they are beginning to respond to the idea of 15 by 15. Where this will go from here is anybody's guess.

Medscape: I noticed that objective 5 in the zero draft is "to strengthen and reorient health systems to address NCD prevention and control through people-centered primary care..." This sounds very positive.

Dr. Roberts: Yes, that was almost verbatim of what we pushed, and I was pleased to see that. In America, we have bought hook, line, and sinker that if you think you have a heart problem, you go to a cardiologist. In fact, I will tell you that if you look at mortality studies, you'll see that you have a higher risk of dying if you do that, mainly because of the "false positive" problem -- unnecessary and sometimes dangerous interventions for those without the disease. There are fascinating studies that show that in areas with higher rates of dermatologists than primary care physicians, there are higher rates of late-stage diagnosis of skin cancer, which has a worse prognosis.[2] In areas with more gastroenterologists, there is more late-stage diagnosis of colon cancer compared with areas with more family doctors.[3]

I think that specialists in a particular area tend to focus on the advanced condition, the extreme, and the unusual. In primary care, we focus on prevention and early detection. If you want to build your system in a way that gets you the best value, you should build it on primary care. As a family doctor, I want to have great specialists to send my patients to. It's just that the patients don't need them as often as the specialists think they do.

Medscape: Objective 5 in the zero document also talks about universal coverage. How would that work globally?

Dr. Roberts: Dr. Margaret Chan, the Director-General of WHO, has taken on universal coverage as a prime issue because she has recognized that you can't deal seriously with chronic disease at a population level without making sure everybody has access to services. And the only way you can do universal coverage is to have a robust primary care foundation. These are felt to be global goals.

Exactly how it will play out financially may vary widely. For example, there may be north-to-south fund transfers to help Somalia with their chronic disease issues. Some funding comes through WHO, which gives out grants to the poorer countries. There are also other sources, such as the Global Fund, an international financing institution that invests money to support large-scale prevention, treatment, and care programs for AIDS, tuberculosis, and malaria. You also have the President's Emergency Plan for AIDS Relief, which was one of George W. Bush's best initiatives. The 2008 legislation authorizes nearly $50 billion over 5 years. It has saved millions of lives in sub-Saharan Africa.

I'm not saying you should not provide funds for AIDS, but what I am against is taking a very vertical approach so that you ignore the horizontal efforts at the community levels. We need to find the balance between the two. Unless we have that, we are going to create distortions that do more harm than good.

Medscape: Is there anything further you'd like to add?

Dr. Roberts: One final thought. How do we get more US students interested in careers in primary care? One way is to offer global health. Over time, people in America are going to be increasingly influenced by and influence global health. If you're a business person who has clients in Hong Kong or Turkey, and you're back on the ground in the United States less than 24 hours after you left one of those places, the health issues that you encounter in one place will affect the other. For example, you may serve as a vector carrying the H1N1 virus from country to country. People are beginning to understand this.