Richard Smith: The moment is coming for chronic disease

Richard SmithAfter years in obscurity, those of us concerned about chronic disease are about to have our moment in the spotlight—at the United Nations High Level Meeting in New York next September. The last comparable meeting was on AIDS in 2001 and led to the Global Fund. Next year’s meeting is described as a “once in a life time opportunity,” but it’s touch and go whether we can seize the opportunity or whether we will blow it.

I wondered on this question as I attended a World Economic Forum meeting in New York on preparing for the meeting. The World Economic Forum is not just that grand meeting in Davos each January but also an organisation of private companies, mostly big multinationals, that works on all sorts of issues throughout the year. The forum has decided that chronic disease is the second major threat to the global economy — and so it’s health section is concentrating on chronic disease rather than the usual AIDS, TB, malaria, and maternal and child health.

It might surprise you that chronic disease is such a major threat to the global economy, and you might be wondering what is meant by chronic disease. One of the big problems for “those of us concerned about chronic disease” is what to call it. What we mean is “cardiovascular disease, diabetes, chronic obstructive pulmonary disease, and the common cancers” not the many other diseases that doctors know to be chronic, including not only neurological, rheumatological, and psychiatric conditions but also, of course, AIDS and TB. We’ve adopted the narrow definition because these problems account for 60% of global deaths and are largely caused by the same risk factors– tobacco, poor diet, physical inactivity, and alcohol.

Another term is “non-communicable diseases” or NCDs, and it seems to be the acronym that’s becoming the most common term. Nobody visits the doctor saying “I have a non-communicable disease” or even “a chronic disease,” and it’s a problem that ordinary people don’t know about the problem that we worry about. One of the main reasons that the AIDS meeting was so successful was that ordinary people knew about the disease and worried about it, and “the AIDS community” included patients, health workers, policy makers, and celebrities and was well organised. The community arrived at the UN meeting knowing what it wanted.

 Those of us concerned about chronic disease are not organised in the same way and may struggle to agree what we want from our UN meeting. What we do have is an impromptu organisation called “the NCD Alliance,” which has been formed by four global organisations covering the four major diseases. Together these organisations comprise 900 organisations from 170 countries, and the membership of these organisations includes patients and health professionals.

The NCD Alliance is determining its “ask” for the UN meeting, but we heard at the World Economic Forum meeting how it’s thinking is going. It wants an emphasis on prevention, measurable and achievable targets with governments being held accountable, coordinated action, implementation of the Framework Convention on Tobacco Control, resources, an agreed approach to countering NCDs, recognition that responding to NCDs is a development issue, addition of NCDs to the successor goals to the Millennium Development Goals, and an emphasis on developing health systems.

It doesn’t want a new Global Fund, although debate is underway on whether the Global Fund should continue to be restricted to AIDS, TB, and malaria or whether it should become a Global Health Fund. But there must be a worry that the “ask” of the alliance is too much and insufficiently focused.

 And the NCD Alliance, representing civil society, is not the only group who will have an “ask” for the UNH meeting. In addition, there will be UN bodies including WHO, national governments, and the private sector. The first thing to be decided, within the next week, is the length of the meeting, and the NCD Alliance would like three days (the length of the AIDS meeting), whereas the European Union and various governments want a one day meeting.

We also heard in New York what WHO would like from the meeting, including a global commitment to countering NCDs, prevention of NCDs to be seen as important for development, high priority to be given by governments to producing plans for NCDs, monitoring and evaluation of progress, and a mechanism for sustainable financing. We also heard what WHO would like from the private sector: pledges to action, (like the ones made by the food industry), monitoring of the problem, plans to scale up effective interventions, an emphasis on workplace health, help to raise global awareness of the problem, and funding.

What does the private sector want and what can we offer? Well, we’re still working it out, but the main “ask” is to be seen as part of the solution not part of the problem. Tobacco companies clearly are part of the problem and are excluded from the World Economic Forum. Food companies are keen to be part of the solution—hence their pledges. Alcohol companies are more worried than most, and pharmaceutical companies should be part of the solution as lifestyle and environmental changes won’t be enough to prevent and control chronic disease.

Ideally, it seems to me, those of concerned about chronic disease (or NCDs) from every sector would agree before the UN meeting a clear, focused, achievable plan plus a mechanism for achieving the plan, including financial investment. In order to avoid the problem of “vertical programmes [those concentrating on one disease]” undermining overall health care we should concentrate on those things—like commitment to health as a development issue, prevention, workplace health, and improvement of health systems—that will work for everybody no matter what their health problems.

If we have such agreement before the meeting it should be a success, but if we don’t it may be a failure. Can we achieve that agreement? I hope so, but I’m far from sure.

Competing interest: RS is the director of the UnitedHealth Chronic Disease Initiative. UnitedHealth is a large, for profit health and wellbeing company, and its Chronic Disease Initiative is a philanthropic programme that collaborates with the National Heart, Lung, and Blood Institute to create 11 centres in low and middle income countries to counter chronic disease.

  • Desmond O'Neill

    The arbitrary exclusion of stroke* and dementia, among the most costly of chronic diseases in human and economic terms, is unhelpful and weakens not only the intellectual coherence of the concept but also adherence to the potential coalition of those concerned with fresh approach to the prevention, detection and management of chronic disease.

    There are clear links with same causative factors for stroke and dementia as for the more circumscribed, historical, list, which seems to lean a little more heavily on the single organ illness model than is comfortable in a world where co-morbidity and frailty are increasingly the rule rather than the exception.

    Could occult ageism and apprehension about complexity figure in these calculations? The INTER-STROKE and 10/66 projects have shown the enormity of the challenge faced by these two chronic diseases in low and middle income countries, and we do little service to chronic disease to unhook their fate from those of other people with other chronic diseases.

    Desmond O'Neill
    President, European Union Geriatric Medicine Society


  • Enrique Sanchez Delgado

    Start focusing in high risk young people, with obesity and hig resting heart rate (high Pulse Mass Index), which is the most simple clinical way to indentify these potential chronic patients that will damage their own health and the economy.

    Enrique Sánchez Delgado

    Managua, Nicaragua

    Lancet.Volume 353, Number 9156 13 March 1999

    Lifetime risk of developing coronary heart disease

  • This looks like a global totalitarian governance agenda. A way of raising money in the name of health & science to force people away from their freedom to make their own choices.

    “Prevention” is not a road to economic growth and it will never be. If prevention means prohibiting people from making their own choices, prevention will automatically lead to economic depression.

    This is because prevention deprives people from the right to make mistakes. Making mistakes, and learning from them, is the way humans create growth.

    What ever happened to good treatment and real science? Don't the people deserve that anymore? Did it vanish completely in the hunt for grants from the pharmaceutical & prevention industries?

  • Richard Smith

    Dear Desmond,

    Stroke is not excluded, although dementia is. There are, however, other initiatives to respond to dementia and other mental health problems.


  • Peter Jacobsen

    It is noteworthy that the four causes of chronic disease you note — tobacco, poor diet, physical inactivity, and alcohol — are all regulated products. (Substitute cars for physical inactivity; cars reduce physical activity for their users, and discourage it for the non-users. Who wants to walk or bike among those speeding hunks of steel? We're not stupid…)

    Health has a big shift to make from fighting infectuous disease to fighting advertising. It's done it fairly well with tobacco. Why is so hard to 'sell' health?