Let’s envisage a new, better normal for all non communicable diseases

The covid-19 pandemic has seen unprecedented action by governments to restrict the movement of most of the world’s population from international travel and access to non-essential services and public spaces. While covid-19 is rightly at the forefront of our minds, we want to shine a spotlight on the biggest killers of the 21st century—non-communicable diseases (NCDs). 

NCDs are the leading cause of premature mortality globally and result in vast health, social and economic costs. The major NCDs, including diabetes, heart diseases and non alcoholic fatty liver disease (NAFLD), share many common risk factors, including sedentary lifestyles and poor diets, among others. These contributors disproportionately impact the poor in many countries, as covid-19 now does. Notably, several NCDs are also known risk factors for covid-19, highlighting the indirect health implications of these diseases. 

As covid-19 infection rates fall, discussions will turn to the way societies will function in the medium to long term, what is being termed “the new normal.” This presents a once-in-a-generation opportunity to put public health at the centre of societies and to shape and deliver holistic responses to the major health challenges of the 21st century, from covid-19 to NCDs such as NAFLD, obesity, diabetes, cardiovascular disease and mental health. 

Addressing NCDs, such as NAFLD, is not only about reducing the prevalence of disease, but also building resilience and reducing vulnerability so as to ensure healthier, more sustainable, and more prosperous societies. Fortunately, we know a great deal about what needs to be done, for example, from reengineering transport systems so that cities are more walkable and bikeable and public green spaces more accessible, to transforming food systems so they deliver healthy affordable diets to all. 

These efforts are not only about improving health, but about social justice. During the current crisis, politicians have championed that we are all in this together, but it is very clear that the lived reality varies widely within society. Not everybody has the luxury of an indoor bike, access to private outdoor areas or the privilege of large living spaces—let alone access to adequate healthcare, economic security, or safe housing. One of the consequences has been a drastic reduction in physical activity, which has implications for physical and mental wellbeing. In many countries, NCDs often follow a social gradient, disproportionately impacting those of lower social-economic status. A dramatic reduction and delaying of primary care health-seeking, cancer and diabetes screening attendance and secondary prevention adherence for chronic disease observed in many societies during covid-19 may further accelerate health inequities. With this opportunity to envisage a new future, we must put equity at the heart of our responses, ensuring that whatever action is taken reduces, rather than compounds, existing inequities. This starts with engaging and empowering affected communities to drive the process. 

The Sustainable Development Goals (SDGs) provide a foundation for action, from health (SDG3), food and nutrition (SDG2) and sustainable cities (SDG11) to climate action (SDG13) and inequality (SDG10). To be successful, we need to combine these agendas to comprehend the complex systems and trade-offs in policy decisions. This calls for new, more collaborative ways of working, including uniting diverse groups of activities, from health and climate change to new economies, in order to innovate solutions and amplify their collective voices.  While the SDGs are adopted by countries, change can start at the city level. This has already begun. Examples of this during the covid-19 pandemic include Milan announcing an ambitious plan to reduce car use by expanding bike infrastructure and improving walkability. Other cities such as Berlin have introduced temporary bike lanes, while London, Manchester, and Brighton plan to introduce restrictions on cars to make exercising safer. Such approaches not only enable people to be more active, but make public transport safer for those who require it, while also lowering noise and air pollution levels, benefitting human health and the planet. 

We suggest the biggest enemy in the battle against NCDs is inaction. More than five years ago, WHO termed the scale of the problem posed by NCDs and the weak international response a “global scandal,” leading some to ask “where is the anger and the activism”? So, what has happened in the past five years to shift the dial? With politicians and the general public acutely aware of the importance of public health due to the current pandemic, now is the time to move from inaction to long-lasting action. We urge politicians to engage with their constituents and stakeholders from across sectors and disciplines to come together to find common solutions to multiple challenges at once. We must strive for a “new normal” that is a “better normal,” one in which our towns and cities become the foundation upon which healthier and more sustainable societies are built.

Jeffrey V Lazarus is head of the health systems team at the Barcelona Institute for Global Health (ISGlobal) and an Associate Professor at the Faculty of Medicine, University of Barcelona, Barcelona, Spain and vice-chair of the EASL International Liver Foundation. @JVLazarus

Henry Mark, EASL International Liver Foundation, Geneva, Switzerland. @HenryEMark

Terry T.-K. Huang is Professor and Chair of the Department of Health Policy and Management, Director of the Center for Systems and Community Design, and Co-Director of the NYU-CUNY Prevention Research Center, Graduate School of Public Health and Health Policy, City University of New York, USA.

Alessandro Demaio, fellow at Melbourne School of Population & Global Health, University of Melbourne, Australia and CEO of VicHealth. 

Competing interests: Jeffrey V Lazarus reports research grants from Genfit, Gilead and Intercept, outside of the work discussed here.  Henry Mark, Terry T-K Huang and Alessandro Demaio have read and understood BMJ policy on competing interests. They declare no competing interests relevant to this article.