Richard Smith: A diary of the UN meeting on NCDs

Richard SmithSaturday 17 September. Day minus two

17.20 Arrive in New York. A bigger queue than ever at immigration. Do they really want visitors?
After an hour I reach the booth.
“When were you in Pakistan?”
“Just over a year ago.”
“What do you do?”
“I run a programme in developing countries working on heart disease and diabetes.”
“Is Pakistan a developing country?”

18.05 Woman on the train to Penn Station in a painfully short skirt describes her wedding night in a loud voice and graphic detail to her three friends.

18.10 Arrive at Penn Station. I always love the buzz of arriving in New York. It’s my favourite city in the US and one of my favourites anywhere. Huge crowds outside the station. As we surge across the road it feels more like Dhaka than New York. Last week’s Economist said how New Yorkers speak 800 languages, several of them near extinction.

18.45 Arrive at my hotel. It’s my smallest hotel room yet in New York, a triumph of fitting everything necessary into a room the size of a Victorian wardrobe. The hotel is right beside the Church of Scientology, which is huge. I’m tempted to go in the same way that I’m tempted to jump off a cliff or under a huge train. I don’t.

Sunday 18 September. Day minus one

06.45 It’s surprisingly difficult to buy a New York Times in mid- town Manhattan. I had planned to go the Frick, a wonderful museum with stunning pictures including Bellini’s painting of St Francis, but I see that MOMA has a de Kooning exhibition. I always seek out his pictures so I must got. I have to go to the UN between noon and 5 pm to get my security clearance. I’m expecting a big queue and planning accordingly.

9.15 Queuing for a cappuccino I overhear: “If you’re on a salary all you do is try and cut time. If you’re an entrepreneur there’s never enough time.”
I ask for pain au raisin. “What? That’s a Danish.”

9.20 I’m always amazed that Americans—and particularly New Yorkers—never walk on escalators or walkways.

9.25 Discussion on CNN about Palestine applying for membership of the UN. Looks like that’s the issue that will dominate the week in the media. I haven’t hear any mention yet of the meeting on NCDs.

10.50 Arrive at MOMA and discover there is no problem with getting a ticket to the de Kooning exhibition. It proves to be stunning, so much so that I spend $59 on the catalogue, something I rarely do because the reproductions are always so disappointing compared with the paintings. de Kooning painted over seven decades, and the exhibition shows how he evolved dramatically, making big jumps at some points. As is common with painters, it took him 20 years to “find his voice.” He trod an unfashionable line between abstract and representative art, and his third series of woman paintings, probably the high point of his career in the 40s, were howled down by many—in retrospect because they were so intense and original. It’s always tough to be truly original, so lucky that most of us aren’t.

This exhibition has justified my trip to New York even if everything else is hopeless, which seems a possibility.

12.40 Walking to the UN building I pass the “Manchester Pub.” It’s packed, and I remember that Manchester United are playing Chelsea. I look through the door to see the score and see Torres pass the goalkeeper and then miss a wide open girl. I feel his pain 3000 miles away. (For those who don’t know anything about football, Chelsea paid millions for Torres, a great scorer of goals, and since joining them months ago he’s scored only one goal. Something has gone horribly wrong.)

12.50 Arrive at the UN. The queues are small. I pass though the security tent quickly, enter the main building, and join a short queue for my tickets. I bump into two colleagues, which seems against the rule of chance when there are supposed to be thousands here. I discover that a) I have a ticket for only one round table and that b) Andrew Lansley not David Cameron is representing Britain and is speaking in the first plenary. These are disappointments. Somebody in the queue says that no Western leaders are coming. Does she know?

1.25 While waiting for my ticket for the second plenary I learn from a powerful exhibition of photos that there are 12 million stateless people in the world. Being stateless is bad, you are shut out from almost everything—education, healthcare, the law.

2.15 I finally buy a New York Times. Despite the fading of both newspapers and the US it’s still 2.5 inches thick. I’ll throw away 2 of those inches, which will make me feel bad.

3.05 Television pundits beginning to think that Obama won’t be re-elected.

4.45 Reflecting that it’s now more than 40 years since I first visited New York, I make my way on the subway to the New York Academy of Medicine. My bias is that the New York subway is more confusing than the London tube because there are fewer maps, poorer signposting, and express trains that go straight through many stations.

5.20 I realise I’m arriving at the academy when I see Latin round the top of a building. It’s not a grand building. Inside I immediately bump into many of the “NCD club” and kiss three women from three different continents within the first minute. The club roams the globe, meeting in all sorts of exotic locations. Our biggest problem is perhaps that we haven’t reached out to the broader population.

5.40 The meeting was supposed to start 10 minutes ago. I fear that’s how it will be all week.

5.42 A man gives me a document that calls on the UN to distinguish between BINGOs (Business Interest NGOs) and PINGOs (Public Interest NGOs). Nice acronyms, I think.

5.45 Eventually a “media type” with a deep voice and a British accent starts the proceedings. He doesn’t tell us who he is, clearly knows little about NCDs, and tells a bad joke. (Isn’t he enough of a “media type” to know that jokes don’t work well with international audiences and aren’t needed anyway?)

5.50 After a brief video on the problem (all words because you can then make it very cheaply), the media type introduces “the” first lady of South Africa. I can’t help thinking that she is “one of” the first ladies—because Jacob Zuma has five wives, to the distaste of many South Africans. Evidently his wives take particular responsibilities, like ministers. Imagine the kitchen cabinet. Tobeka Madiba-Zuma reads her speech like somebody reading a lesson in church, hesitantly and without much meaning.

6.00 Finally we get to some meat. David Bloom from the Harvard School of Public Health has been leading a team sponsored by the World Economic Forum to put a price tag on NCDs. The report is published here today. He says that we have the perfect storm (doesn’t he know that that was last year’s cliché?) of global spread of risk factors, population growth, and ageing.

He describes his study as a “first chapter rather than a last chapter” as they faced many tricky problems and had to make many assumptions. They have costed the main four conditions and mental health from 2010 to 2030 using three methods: cost of illness, macroeconomic simulation, and willingness to pay. The costs arise from lost income, reduced productivity, and health costs.

The headline figure is the unimaginable $47 trillion. For context this is 75% of the global GDP, 10 times the global annual health spend, 25 times all aid for the past 20 years, and roughly the sum needed to eliminate people living on $2 or less a day.

A third is the cost of cardiovascular disease and 33% mental health.

The sum is big enough to create huge economic problems, and the two main messages, concluded Bloom, are that NCDs matter and that they matter a lot.

6.10 Next came Ala Alwan, assistant director general of WHO responsible for NCDs and mental health, who presented a new study on the cost of scaling up measures to counter NCDs. WHO has already worked out the “best buys” for countering NCDs, and they include both population and individual measures, targeted screening, and early prevention (of cardiovascular disease and cervical cancer), a primary care approach, and integrating care of patients with cardiovascular disease and diabetes.

The annual cost for all low and middle income countries is $2 billion ($0.20 per person) for population measures and $10 billion for individual measures ($1 per person in low income countries).

6.25 After a couple more dignitaries making their pitch, questions began. A woman jumped up and said that NCDs were “corporate led” and that the WHO wasn’t doing enough about conflicts of interest. Somebody pointed out that there were no data on what might be gained from investing in programmes for NCDs, while somebody else said that the contrast between the costs and the sums needed for responding surely showed that investing in preventing and controlling NCDs would produce a great return on investment.

7.05 A few more kisses and back on the subway.

9.30 To sleep after watching five minutes of the Emmy awards. What terrible thank you speeches.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.