Richard Smith: UN meeting on non-communicable diseases goes wobbly

Richard SmithThings are not going well with the UN high level meeting on non-communicable diseases (NCDs) that will take place in New York in a month’s time. The aim was to have completed negotiations on the outcomes document before the UN closed for its summer break, but this wasn’t achieved.

The member states causing the most difficulties are the European Union, which is negotiating as a block led by Poland, and the United States, with Canada and the Russian Federation also being unhelpful. With stock markets crashing and the Euro looking very vulnerable, it’s easy to see why resources are one of the sticking points. It seems unlikely to me that rich countries will sign up to any serious commitment to funding. They might sign a document that says something like “continue to explore the possibility of…..,” in other words, no commitment at all.

Would a document with no commitment to funding be worth having? I think it would because much of what needs to be done to combat NCDs does not depend on funding — things like raising taxes on tobacco, alcohol, and other unhealthy products, banning smoking in public places, or working with food companies to reduce salt, sugar,and fat in their products.

Other sticking points involve trade agreements, intellectual property, and essential medicines and vaccines. The problems here boil down to money as well, but there are also disputes over risk factors (tobacco, poor diet, physical inactivity, and the harmful use of alcohol). Some members states seem not to want an emphasis on risk factors, which is unfortunate as many of us interested in NCDs think that this is the most cost effective level at which to act.

Some of the resistance may stem from lobbying from tobacco, alcohol, and food companies, but arguments over physical inactivity seem to revolve around the science. The evidence on physical activity is not as strong as that for tobacco, which is very strong, but I think that we have good evidence that physical inactivity is harmful and that physical activity is beneficial. Where evidence may be weaker is over which interventions are effective in increasing levels of physical activity, but I can’t see strong arguments for excluding physical activity on scientific grounds. Maybe there are shadier reasons that I haven’t grasped.

Another understandable difficulty is countries in Africa not wanting to be diverted from infectious disease and maternal and child health, the main targets of the Millennium Development Goals. Those of us working on NCDs don’t want anybody to be diverted from those problems, and health system strengthening, which will be included in the outcomes document, should be good for everybody.

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 meeting is also dogged by logistical problems. People from NGOs, academia, and the private sector will be invited, but they have not been invited yet. There will hardly be time to book flights and hotels. Nor have invitations gone out to the heads of state and government. More of them than usual are expected to attend the UN General Assembly but it’s not clear how many will attend the meeting on NCDs. The leaders of Brazil, Chile, Indonesia, Kenya, Mexico, Nigeria, South Africa, and Trinidad and Tobago have intimated that they will be there, but it’s not certain. It’s noticeable to me that these are all low and middle income countries: contrary to a common myth, they are the countries feeing the most pain from NCDs.

It will undermine the importance of the meeting if few heads of state and government turn up, but it’s not hard to see that the political pressure on them to attend is not strong. I’ve been speaking about NCDs in many countries, and I always ask people how many have heard of the UN meeting. Usually nobody has—and these are people who have come to a meeting on NCDs, not people in the street. In contrast to AIDS in 2001, the subject of the last UN meeting, nobody in the street in 2011 knows what NCDs are. So leaders like David Cameron might be criticised not for not going, but rather for going to a meeting on NCDs when London is burning and economies are collapsing.

But the meeting has actually achieved a lot already. It has raised consciousness about NCDs among governments and other organisations and prompted spirited debates on how best to respond. Let’s hope for still more. Global meetings seem to be like basketball games in that everything is decided in the final few moments.

Competing interest: RS directs the UnitedHealth Chronic Disease Initiative, which together with the National Heart, Lung, and Blood Institute funds 11 centres in low and middle income countries working on NCDs. He’s still hoping to get an invitation to the UN meeting.

Richard Smith was the editor of the BMJ until 2004.