Bumpy ride for UN conference on non-communicative diseases

It should surprise nobody that a global conference on non-communicative diseases fails to get to the top of most people's priorities. Former editor of the British Medical Journal Richard Smith discusses the forthcoming UN summit on non-communicable diseases (September in New York) – admits to no little surprise that there seems to be limited enthusiasm for it and contemplates the merits of a global resolution on this issue that is unsupported by any funding.

The summit focuses on four risk factors: tobacco use, alcohol misuse, physical inactivity and inadequate diet. These are leading factors in cancers, cardiovascular disease, COPD and diabetes.

Lancet editor Richard Horton observed earlier this year that the non-communicable disease agenda lacks the urgency of other issues.

Although 80% of NCD deaths take place in low and middle-income countries, the fact is that for the 50 or so poorest countries in the world an unfinished litany of problems remains—infectious diseases, maternal and childhood illnesses, and unchecked population growth. NCDs come bottom of this list.

Richard Smith still seems to feel it is worth while keeping on the table as an issue for the NCD Alliance. But the NCD Alliance seems to be losing patience with the rest of the world:

A particular problem for the NCD Alliance, a quickly formed global body of organisations concerned about NCDs, is that the outcome document lacks clear targets, meaning that member states can easily slide away from doing anything. There are also disagreements over follow up and the need for partnerships. The alliance says that its time to “stop being polite.” They want outrage.

The issues that concern the NCD Alliance seem far too important to leave at the table of a hastily formed group of non-governmental organisations, that appears to think it should be an authority on global health issues ... an authority with teeth, that can enforce its will on member states. What can such an alliance actually do? Adequate food cannot be guaranteed by a non-governmental body without the willing cooperation of many other actors. Such a body can recommend good diet, but where malnutrition is a recognised issue it won't necessarily help matters to have yet another body declare that everyone needs a balanced diet.

All an international body can do is demand policy changes. Any other kind of intervention costs money.

What kind of policy changes will be advocated? Is this kind of scenario in less developed countries really going to be helpful or relevant?

Mr Smith seems a little surprised that NCDs don't get the attention from the general public that was given to AIDS. The global health agenda seems to have turned upside down since then.

Should tobacco control lead the fight against non-communicable diseases?

Unlike the Framework Convention for Tobacco Control I can't see the need for the fight against non-communicable diseases to be led by tobacco control. Tobacco control is a single issue – non-communicable diseases are various in their causes and manifestations.

Worldmapper sets out the incidence of non-communicable diseases across the world in some detail. Starting on this page we can see from a list how, with a broad brush, smoking-related deaths account for some four-fifths of non-communicable diseases. But start clicking on the maps (go to 'next map') featuring each kind of cancer, many cancers do not mention smoking as a factor, and the description of lung cancer mentions other significant risk factors. (Go here for a comprehensive index of causes of death.) In fact the FCA tells us that tobacco causes 1 in 6 deaths from non-communicable diseases (and that it makes people with other conditions more likely to die).

Aside from factors in deaths, when considering who should lead the global fight against non-communicable diseases, we should also consider the ages at which people die and tackle first those conditions that kill younger people rather than older ones. A very broad brush suggests that non-communicable diseases are less prevalent in countries where people tend to die at a younger age. From here, go to 'next map', keep clicking and you will see that the people who live longest die in the rich world ... obvious, but we are told that most deaths are from non-communicable diseases.

The Framework Convention Alliance's report is clearly geared to a market of concern for developing countries.  I am already finding it difficult to see why tobacco control should lead 'the fight against non-communicable diseases'. Why should non-communicable diseases be prioritised if we are trying to save young breadwinners', children's and infants' lives in the poorest areas of the world? Surely there are diseases that afflict people in poor countries but they are not all tobacco related, and surely diseases that people can transmit to each other are far more dangerous anyway.

How about this for a reason to focus on tobacco control:

Unlike malaria, AIDS or neglected tropical diseases, where the vector is a mosquito, virus or parasite, tobacco has a human vector in the shape of a wealthy, powerful, multinational industry. Tobacco industry revenue dwarfs the GDP of many countries and the industry has used its billions to aggressively market its products in low and middle income countries. As the world strives to reduce poverty, tackle the financial crisis, food insecurity and climate change, no country can afford the health, economic or environmental consequences of tobacco use. [...]

We'll fight tobacco because it's represented by a human agent. They're bad people who profit from death ... unlike the poor mosquito? Forcing people to spend money on them ...

A unique feature of the tobacco pandemic is that after more than half a century of research and analysis, we know how to reduce this burden. Not only that, but we have an internationally negotiated, legally binding package of evidence-based tobacco control measures, the WHO Framework Convention on Tobacco Control, to which more than 170 WHO Member States are Parties, accounting for more than 85% of the global population.

[but they don't know how to reduce the burden. All they do is to move it about – in fact they have shifted the burden of tobacco from the rich world to the poor world. They have banned advertising in one part of the world and splutter with indignation whenever tobacco companies find somewhere they are still allowed to advertise. In fact they still describe tobacco-related disease as 'preventable'.]

Effective tobacco control policies reduce NCDs: the incidence of cardiovascular and respiratory disease falls first, followed by cancer and other diseases.

As exemplified by Jill Pell who discovered a 17 per cent reduction in heart attack admissions and an 18 per cent reduction in admissions for childhood asthma following the implementation of the smoking ban in Scotland,

... Health-care costs are reduced and productivity is increased. They can also generate significant government revenues. Increasing tobacco taxes does more than any other single measure, at least in the short term, to decrease tobacco use. Appropriately structured, tobacco taxes have the potential to pay for tobacco control, for action on other NCDs or for any other useful public purposes governments may choose.

The triumph of hope over experience? Is there not something of a conflict of interest in relying on tobacco sales for funding to promote tobacco control? Spain has seen a price war in tobacco following its smoking ban ... isn't this a likely consequence of further increasing tobacco taxes?

Global tobacco control can and should be the lead engine

That is the conclusion of one of the world’s pre-eminent public policy institutions, the Center for Strategic and International Studies, in its analysis of the potential of the UN High-level Meeting on NCDs (19-20 September 2011) to elevate NCDs onto the global stage. Many of the world’s most knowledgeable scientists, key non-governmental organisations, and public health workers in low, middle and high income countries are already engaged in marshalling the data and proposing priority actions to make immediate and sustainable progress.

The FCA document seems to do little but recommend a power grab by tobacco control interests, describing the Framework Convention on Tobacco Control to the exclusion of everything else, boasting of the success of tobacco control measures (in a box headed 'Evidence' but containing only assertions) – even offering a wild guess as to how many more people would survive tuberculosis if they didn't smoke. Remember Richard Horton's view:

Although 80% of NCD deaths take place in low and middle-income countries, the fact is that for the 50 or so poorest countries in the world an unfinished litany of problems remains—infectious diseases, maternal and childhood illnesses, and unchecked population growth. NCDs come bottom of this list.

The document insists that the measures described are cheap – but just because they are cheap does not mean they should be prioritised. Unfortunately the Framework Convention on Tobacco Control gives the FCA grounds to claim that countries have international obligations and have no choice on this issue. This should be viewed as a violation of national integrity by countries everywhere. In fact the creation of this treaty as the first binding multilateral treaty of the WHO should be cause for alarm. This document shows an over-riding concern to fight an industry rather than to tackle the complex issues surrounding premature death in the developing world.

Richard Horton talks up NCD agenda, Moscow, April 2011

Richard Horton winds up discussion of a disorganised and frustrating event by describing the unexpected charisma of Vladimir Putin, who addressed the first global ministerial conference on healthy lifestyles and non-communicable disease (NCD) control. He then makes an intriguing case for resources to be given to non-communicable disease control:

Although 80% of NCD deaths take place in low and middle-income countries, the fact is that for the 50 or so poorest countries in the world an unfinished litany of problems remains—infectious diseases, maternal and childhood illnesses, and unchecked population growth. NCDs come bottom of this list.

Quite rightly so. Diseases that can't pass from one person to another, whose cause is usually multi-factorial and can't be isolated and analysed, come a long way down the pecking order of complaints that a world health authority should turn its hand to – especially when people are dying in ways that should be cheap and easy to prevent.

If we are to make any progress at all in getting NCDs noticed, we’ll have to show how their prevention and treatment can easily be integrated into existing health programmes that are already struggling in health systems starved of cash and capacity.

How can you prevent something when you don't know what causes it? How, also, can you do it at no cost?

Another big vertical initiative is not what countries want or need. This points to an uncomfortable truth—we in the health community have not made an effective business case for NCDs. Deaths alone are not enough. We need to show why NCDs matter—and they do—for economic stability as well as poverty reduction. The macroeconomic case for action is lacking: an urgent gap to fill between now and September.

 So what is the 'business case' for emphasising NCDs, when Horton himself admits they are at the bottom of the heap as far as poor people's priorities go?

My cynicism knows no bounds perhaps, but the Framework Convention Alliance's interest in this conference indicates that tobacco control can be found lurking. I just hope that their keenness to promote the cause of NCDs doesn't lead to people being pressurised to sack employees who smoke, or otherwise make their lives difficult. I'm also intrigued about exactly what the conferences imagine they can do cheaply and easily to prevent non-communicable diseases ... but since they wish to discuss them at inter-government level this September, perhaps it won't be long before we find out.