The sociopolitical landscape of NCDs, Part II
5.1 Tackling NCDs: towards a global response
Following decades of neglect and inaction, the issue of non-communicable disease (NCD) has finally grabbed the attention of policy-makers globally.
As described in Chapter 4, NCDs were for decades regarded as being of little relevance to low- and middle-income countries (LMICs). NCDs were excluded from the global health agenda and neglected in development discussions.
Between 2000 and 2011, however, this apathy gradually dissipated as increasing attention focused on NCDs as a global issue. This was achieved through a number of global strategies and action plans, culminating in the UN High-Level Meeting on NCDs—and its resulting political declaration—in September 2011.
Recent events give grounds for optimism that the world has moved beyond these periods of, first, apathy and, subsequently, attention into a period of action (Box 5.1). In May 2013, the WHO Global NCD Action Plan for 2013–2020 was adopted by 194 ministries of health at the sixty-sixth World Health Assembly.
This action plan sets out nine voluntary targets on NCDs (Figure 5.1). Countries are committed to working towards the achievement of these targets by 2025. Four of these targets relate to behavioural risk factors (alcohol, physical inactivity, salt/sodium, tobacco), two relate to intermediate outcomes (blood pressure and diabetes/obesity), and two relate to health systems. The overall target of a 25% reduction in premature mortality by 2025 is considered to be ambitious on a global scale.
It is important to stress that countries are expected to set their own national targets, adapted to the national context. Many high-income countries already have falling mortality rates, for example, so it may be appropriate to set a more ambitious overall target.
5.2 NCD control and prevention to achieve the sustainable development goals
Further evidence of this building global momentum is provided by the incorporation of NCDs into the latest global development agenda. At the United Nations Sustainable Development Summit on 25 September 2015, world leaders adopted the 2030 Agenda for Sustainable Development, which includes a set of 17 sustainable development goals (SDGs) to end poverty, fight inequality, and injustice, and tackle climate change by 2030.1 The sustainable development agenda incorporates a number of targets directly related to NCDs (see Box 5.2).
Source: data from United Nations. Sustainable Development Knowledge Platform, ‘Transforming our world: the 2030 Agenda for Sustainable Development’, https://sustainabledevelopment.un.org/post2015/transformingourworld, accessed 18 Jul. 2016, Copyright © 2015 United Nations.
More broadly, efforts to address NCDs and their risk factors are closely aligned with this sustainable development agenda. Prioritizing NCD prevention and control will ensure that each country achieves these 17 goals in an efficient manner, simultaneously protecting human health and the environment, ultimately leading to widespread sustainable development. Furthermore, partnered approaches to the prevention and control of NCDs resonates with the ‘integrated and indivisible’ nature of the 2030 Agenda for Sustainable Development. The NCD-related targets may reside under the health goal, but approaches to achieving these targets cut across many of the other goals, most of which deal with social, economic, and environmental determinants of health.2 There are, therefore, many direct and indirect links between decreasing the NCD burden and achieving a nation’s SDGs.
Goal 1—End poverty in all its forms everywhere.
NCDs are a development issue because of loss of household income from unhealthy behaviours, from loss of productivity (due to disease, disability, and premature death), and from the high cost of health care, which can drive families below the poverty line. Additionally, people’s exposure to tobacco use, unhealthy diets, physical inactivity, and the harmful use of alcohol is much higher in developing countries than in high-income countries where people tend to be protected by comprehensive interventions. The cost of buying tobacco and alcohol also diverts household income and resources from ensuring food and nutrition security. Spending on tobacco and alcohol is more detrimental to the poor as their resources are limited.3 It is important that those involved in poverty eradication and development consider not only the economic impacts of their interventions, but also their impacts on health. Linking NCD prevention with the development agenda is one of the key actions recommended by the WHO.
Goal 2—End hunger, achieve food security and improved nutrition, and promote sustainable agriculture.
One of the 169 proposed targets of the SDGs is to reduce premature deaths from NCDs by one-third; another is to end malnutrition in all its forms.2 Many poorer countries are now beginning to suffer from a double burden of undernutrition and obesity. Nutrition-related NCDs stand at the intersection between malnutrition and NCDs (see section 5.4 later in this chapter for more information on malnutrition and NCDs).
NCD risks often stem from unsustainable environmental systems and practices, such as those related to agriculture and urbanization. Industrialized agriculture and food systems can be a contributing factor in unhealthy diets that are low in fruits, vegetables, pulses, nuts, and whole grains. An increasingly commercialized food system has led to greater availability of processed foods that are high in fats, sugar, and salt—often at the expense of localized food production. People in LMICs are increasingly exposed to these NCD risks as their environments around them change faster than their resources and capacities can protect them.4
Enabling sustainable agriculture can play a role in providing people healthy diets that can help prevent NCDs. A diverse diet with access to healthy food, including fruits and vegetables, and one that is limited in processed foods is important for preventing NCDs. A ‘sustainable food system’ is ‘one that provides healthy food to meet current food needs while maintaining healthy ecosystems that can also provide food for generations to come with minimal negative impact to the environment’.5
Ensuring food security—when all people have access at all times to sufficient, nutritionally adequate and safe food—is a precondition for preventing NCDs. Policies and programmes to improve maternal and infant health and nutrition can reduce a child’s susceptibility for developing NCDs later in life, particularly diabetes and cardiovascular disease. Policies to encourage shifts in agricultural production from commodities such as meat, dairy, palm oil, and tobacco to more fruits and vegetables would reduce greenhouse gas emissions and protect the environment, while also contributing to NCD prevention efforts.
Goal 3—Ensure healthy lives and promote wellbeing for all at all ages.
This SDG directly encompasses NCDs by targeting reducing premature mortality from NCDs by a third through prevention and treatment (target 3.4). Other targets under this goal address the various risk factors of NCDs, including targets to strengthen the prevention and treatment of alcohol abuse and implementing the WHO Framework Convention on Tobacco Control in all countries. The targets also address the interdependency of health outcomes; often communicable diseases and other acute conditions when left untreated can lead to NCDs. Hence, achieving universal health coverage allows access to quality essential health care, and investment in, and access to safe, effective, quality, and affordable essential medicines is of the utmost importance (target 3.8).
Goal 4—Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
NCD prevention starts with education. Schools play an important role in encouraging healthy lifestyles, including physical activity, healthy diet, and avoiding alcohol and tobacco. School feeding programmes are associated with increased school enrolment and attendance can be extended to educate students about healthy dietary practices. As discussed in chapter 4, NCDs have economic costs which have consequences for sectors such as education. The cost of treating NCDs related to tobacco use and harmful alcohol use may mean that fewer resources are available for educating children, especially girls. Reducing tobacco use and the harmful use of alcohol, especially in lower income populations, provides more resources for education.6 Education, in turn, may provide an individual with job opportunities and a potential path to improving their socioeconomic status, which, in turn, may improve their health and the health of their families.
Goal 5—Achieve gender equality and empower all women and girls.
NCDs are a significant cause of poor health and premature death for women in their potentially productive years, particularly in developing countries. As the prevalence or incidence of NCDs rises, young women are increasingly led to assume caregiving roles, which diverts their time and attention away from investing in their education and career.5
Goal 6—Ensure availability and sustainable management of water and sanitation for all.
Over 663 million people worldwide still lack access to safe water.7 At the same time there is an increasing dependency on sugar-sweetened beverages (SSBs). There has been rapid expansion of the SSB industry in LMICs where large portions of the population remain deprived of safe water. The widespread distribution and low cost of these products has led to a scenario in which SSBs are frequently substituted for water. Ensuring the availability of safe water will lead to the decreased consumption and distribution of SSBs, which will help countries attempting to address rising rates of obesity and other fatal chronic illnesses.8
Goal 7—Ensure access to affordable, reliable, sustainable, and modern energy for all.
Around 3 billion people still cook and heat their homes using solid fuels (i.e. wood, crop wastes, charcoal, coal, and dung) in open fires and leaky stoves. This unsustainable and harmful form of energy is more prevalent in LMICs. The use of these inefficient cooking fuels and technologies produces high levels of household air pollution with a range of health-damaging pollutants, including small soot particles that penetrate deep into the lungs. Swapping these methods with cleaner cooking stoves and sources of energy can help prevent illness and death from respiratory and cardiovascular diseases, especially in women and children, who traditionally spend more time at home.
Goal 8—Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all.
Economic costs imposed by NCDs are expected to soar over the next two decades. NCDs are estimated to cause cumulative global economic losses of US$47 trillion by 2030. This constitutes a huge strain on the development process as there is a huge loss of productivity. NCDs strike people in LMICs during their prime working years—much younger than in high-income countries. Close to half of all NCD deaths in LMICs occur below the age of 70, and nearly 30% occur under age 60. Most NCD deaths are preceded by long periods of ill health. Prolonged illness and early death of the main income earner result in loss of productivity, which leads to slowed economic growth and development. There is also an indirect productivity impact when people limit their economic engagement to care for family members with NCDs.9 Economic and employment growth impacts individuals and their wider environments. In some instances, the impacts may be positive. For example, the growth may provide individuals with the resources that they need to take better control of their lifestyle choices. Such growth may also lead to positive changes in their environment, such as improved access to health care. However, as described in Chapter 4, economic growth can also have negative impacts on health. For example, it may correspond with environmental changes that lead to a more sedentary lifestyle and a more unhealthy diet. Therefore, policy-makers should take a more balanced approach to promote both the economy and the population’s health.
Goal 9—Reduce inequality within and among countries.
Social determinants, such as education and income, influence vulnerability to NCDs and exposure to their modifiable risk factors. People of lower education and economic status are increasingly exposed to NCD risks and are disproportionately affected by NCDs. For example, in countries such as Bangladesh, India, Philippines, and Thailand, tobacco use is highest among the least educated and poorest segments of the populations.10 At the same time, NCDs may also contribute to social inequalities. The costs associated with NCDs increase the risk of children missing school and becoming at risk of poverty for the rest of their lives. Addressing the social determinants of NCDs and health more broadly will augment progress towards poverty eradication and foster a more equitable society that supports sustainable development.11
Goal 11—Make cities and human settlements inclusive, safe, resilient, and sustainable.
Rapid unplanned urbanization in developing countries also creates conditions in which people are more exposed to unhealthy goods and physical inactivity.12 Improved urban planning and transport policies can support a shift from private motorized transport to walking, cycling, and public transport—helping to prevent heart disease, diabetes, some cancers, depression, and dementia through increased physical activity. The shift away from motorized transport can also help prevent respiratory and cardiovascular diseases through reductions in air pollution.
Goal 13—Take urgent action to combat climate change and its impacts.
Poor air quality from greenhouse gas emissions increases the risk of developing NCDs such as cancer, cardiovascular disease, and chronic respiratory diseases. Cities account for more than 70% of global carbon dioxide emissions,13 and almost one-quarter of carbon dioxide emissions from global energy use are due to transport. Urban development and transport systems that are not built at a communal scale and pace can also discourage physical activity, which increases a person’s risk of developing cardiovascular disease, diabetes, and some cancers. Climate change can also have direct impacts on health. Extremely high air temperatures contribute directly to deaths from cardiovascular and respiratory disease. Climate change can also impact agriculture, food production, and diets.
Goal 15—Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation, and halt biodiversity loss.
NCDs are linked to the exploitation of natural resources. The rise in palm oil consumption—a risk factor for cardiovascular disease—has been responsible for destruction of rain forests and for soil and water pollution, especially in key palm oil-producing countries, such as Malaysia and Indonesia. Tobacco farming, which contributes to deforestation and soil degradation, has also been responsible for displacing food crops, such as vegetables and pulses in Bangladesh and cassava, millet, and sweet potatoes in Kenya.4
Goal 16—Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels.
National policies in sectors other than health have a major bearing on the risk factors for NCDs. Policy decisions related to agriculture, trade, finance, taxation, food production, pharmaceutical production, industry, education, transportation, and urban development can have a major influence on the population levels of risk factors like tobacco use, unhealthy diet, physical inactivity, overweight and obesity, and harmful alcohol use. Therefore, gains can be achieved much more readily by influencing public policies in these sectors than by making changes in health policy alone. The health system, like many institutions, is negatively affected by war, disaster, and political upheaval. In war and disaster situations, primary health care and NCD prevention activities are often displaced by the more urgent need to manage acute conditions and emergencies. Such changes have a significant impact on prevention and control of NCDs.
5.3 Current global action plans and targets for NCD control
The WHO Global Action Plan For the Prevention and Control of Non-communicable Diseases 2013–2020 (hereafter referred to as the ‘Global NCD Action Plan’ or ‘the Action Plan’) aims to put into practice the promises of the 2011 political declaration on NCDs, which emerged from the high-level meeting at the UN General Assembly in New York.
The Action Plan has six overall objectives (see Box 5.3) and sets an overall global target of reducing premature mortality from NCDs by 25% by 2025.
Reproduced with permission from WHO. Global Action Plan: For the prevention and control of noncommunicable diseases 2013-2030. Geneva: World Health Organization, Copyright © 2016 WHO, http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1, accessed 19 Jul. 2016.
In addition to the nine global goals, 25 indicators have been selected for the global monitoring framework. Countries will then select which monitoring indicators are relevant to their particular context and report their progress towards targets through the global monitoring framework (see Chapter 14).
An important resource for policy-makers is the menu of policy options and cost-effective interventions for NCD prevention and control set out in the Action Plan. (For more information, see Chapter 10.)
The Action Plan seeks to involve a wide range of sectors and stakeholders in NCD prevention and control. This will require collaboration between a wide range of UN agencies, policy-makers, members of civil society, and, where appropriate, the private sector. A key challenge for NCD prevention is to engage policy-makers and stakeholders from non-health sectors such as agriculture, food, transport, urban planning, finance, education, employment, environment, sports, energy, housing, foreign affairs, social welfare, justice, socioeconomic development, tax and revenue, trade and industry, and youth affairs.
With up to 24 UN organizations potentially involved in tackling NCDs, the World Health Assembly asked WHO to work on the division of tasks and responsibilities for international organizations. A UN Interagency Task Force on the Prevention and Control of Noncommunicable Diseases has been formed, by expanding the mandate of the existing United Nations Ad Hoc Interagency Task Force on Tobacco Control, and in 2014, a Global Coordination Mechanism on NCDs was established. This mechanism is led by member states and other participants include UN organizations, private sector and non-governmental organizations (NGOs), and civil society.
5.4 Another element of the global response: Preventing all forms of malnutrition
Global action to tackle NCDs is complemented by international commitments to eradicate hunger and prevent malnutrition in all its forms. Undernutrition remains a major global challenge, directly affecting one in three people. In 2015, while 42 million children under the age of 5 were overweight or obese, 156 million children were stunted by malnutrition. Similarly, 1.9 billion adults were overweight, while at the same time 462 million people were underweight and over 2 billion people suffer from micronutrient deficiencies. These different—and inter-related—forms of malnutrition now coexist in the same countries, communities, households, and even individuals.
There have been a number of important recent global commitments on nutrition, seeking to tackle the multifaceted challenge of malnutrition and this devastating double burden.
On 1 April 2016 the United Nations General Assembly agreed a resolution proclaiming the UN Decade of Action on Nutrition from 2016 to 2025. The resolution aims to trigger intensified action to end hunger and eradicate malnutrition worldwide, and ensure universal access to healthier and more sustainable diets—for all people, whoever they are and wherever they live. It endorses the Rome Declaration on Nutrition and Framework for Action14 issued when ministers and top officials from over 170 countries assembled at the Second International Conference on Nutrition in Rome in November 2014. The Rome Declaration included a number of important commitments (Box 5.4).
Reproduced with permission from Food and Agriculture Organization of the United Nations. © FAO 2014, Second International Conference on Nutrition, Rome, 19-21 November 2014—Conference Outcome Document: Rome Declaration on Nutrition, http://www.fao.org/3/a-mm215e.pdf, accessed 18 Jul. 2016.
The Framework for Action sets out a set of 60 recommended policy programme options for countries to be able to translate the commitments of the Rome Declaration into action. Many of these policy areas are specifically aimed at reversing the rising trends in overweight and obesity and reducing the burden of diet-related NCDs. Given the inter-related nature of the different forms of malnutrition, however, all of the policy areas set out in the Framework for Action have implications for diet-related chronic diseases, reflecting the multifactorial nature of malnutrition and the multisectoral approach required.
The Framework for Action encourages governments to establish nutrition targets and milestones and endorsed the six global nutrition targets to be achieved by 2025 set out in the Comprehensive Implementation Plan on Maternal, Infant, and Young Child Nutrition, endorsed by the World Health Assembly (WHA) in May 2012.
The six global nutrition targets to be achieved by 2025 are:
• 40% reduction in the number of children under 5 who are stunted;
• 50% reduction of anaemia in women of reproductive age;
• 30% reduction in low birth weight;
• No increase on childhood overweight;
• Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%; and
• Reduce and maintain childhood wasting to less than 5%.
It is immediately obvious that Target 4 on childhood overweight relates to NCDs. In fact, however, there are other strong links between maternal, infant, and young child nutrition and NCDs and their risk factors. Prenatal malnutrition, low birth weight, and undernutrition in early life create a predisposition to obesity, high blood pressure, heart disease, and diabetes in later life, as shown in Figure 5.2.
The Comprehensive Implementation Plan follows the same timeframe as the Global NCD Action Plan. It sets out five high-priority actions for member states and a global monitoring framework to measure progress on implementing the plan has been developed.
This chapter is drawn from the presentations by Dr Shanti Mendis and Kaia Engesveen, with additional material provided by Jessica Pullar and Nousin Hussain.
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