Prioritizing Noncommunicable Disease Prevention and Treatment in Global Health

The American Public Health Association,

(APHA) has previously taken a position on various noncommunicable disease issues, but it has not previously addressed the issue comprehensively with respect to global health. Because none of the previous policies have dealt specifically with this issue, they should not be archived. Among previous related APHA policy statements are the following.

Policy Statement 9101, “Childhood Asthma: A Major Public Health Problem,” in which APHA called attention to a major noncommunicable disease that affects a significant proportion of American children, and which is largely preventable and treatable.¹

Policy Statement 9202, “The Prevention of Diet-Related Chronic Diseases,” in which APHA noted the proven and suspected connections between unhealthy diets and noncommunicable diseases, including diabetes and cancer.²

Policy Statement 20038, “Supporting a Nationwide Environmental and Health Tracking Network to Identify Links Between the Environment and Human Health,” in which APHA recommended the creation of a national surveillance system to better understand the connections between environmental contaminants and health.³

Policy Statement 200615, “A Call for a Framework Convention on Alcohol Control,” in which APHA supported the creation of an international convention on alcoholism and alcohol abuse parallel to the regime created by the UN Framework Convention on Tobacco Control.⁴

Policy Statement 20089, “Strengthening Health Systems in Developing Countries,” in which APHA addressed the need to build support for health professionals and facilities in other countries to sustainably manage health care.⁵

Policy Statement 20094, “Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health,” in which APHA supported the creation of and fulfillment of the UN Millennium Development Goals, several of which explicitly link health outcomes with social determinants and poverty.⁶

Problem Statement

The leading causes of death, according to the World Health Organization (WHO), are 4 main chronic illnesses, which the organization and other global health agencies group together: cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. These conditions killed more than 43 million people in 2010, approximately 63% of all deaths worldwide. Among the proven risk factors for these conditions are smoking, dietary patterns, disabilities, exposure to indoor air pollution, and poverty.^7,8

In addition, institutions with public health responsibilities often identify injuries (including those from road traffic accidents),⁹ mental illness,¹⁰ and birth defects¹¹ as significant additional causes of morbidity and mortality. 

Deaths from so-called “noncommunicable diseases” (NCDs) are not limited to wealthy or heavily industrialized countries like the United States. An increasing proportion of WHO’s 4 main NCDs, perhaps 80%, now occur in low- and moderate-income countries. In some places, women and children face special barriers to the prevention and treatment of NCDs,^12,13 and the burden of these diseases on those least able to cope with them is becoming heavier. According to WHO, NCD mortality will increase to 49.7 million in 2020, an overall rise of 17%, with the greatest increases in Africa (27%) and the Eastern Mediterranean region (25%). Overall, the highest absolute number of deaths from NCDs by 2020 will occur in the Western Pacific and Southeast Asia. The incidence of NCDs in the United States and other developed nations is expected to remain stable or decline slightly during this period.^7,8,14 It is important to note that individuals can have more than one NCD at a time; in fact, many millions of people do.

Hundreds of millions of people worldwide are affected by mental disorders. WHO estimates that 151 million people suffer from depression, 30 million from bipolar disorder, and 25 million from schizophrenia; 125 million people are affected by alcohol use disorders. As many as 40 million people suffer from epilepsy and 24 million from Alzheimer’s disease and other dementias. In 2004, mental disorders accounted for 13% of the global burden of disease, defined as premature death combined with years lived with disability. When only the disability component of the burden of disease calculation is taken into account, mental disorders accounted for around one third of all years lived with disability.⁹

More than 1.2 million people die on the world’s roads each year, and some 50 million more are injured. More than 90% of these deaths occur in low- and medium-income countries. The cost of rehabilitation and long-term care for accident victims can financially ruin all but the wealthiest families, and place inordinate strain upon national health budgets.¹⁰

According to the US Centers for Disease Control and Prevention, 1 of every 33 babies born in the United States possesses a birth defect. Birth defects are the leading causes of death among neonates, responsible for more than 20% of all deaths in this group.¹¹ Comparable statistics are not available globally.

The global health community has long recognized that the social determinants of health contribute heavily to NCD prevalence.^7,8,15–25 Some lifestyle risk factors rise considerably among the poor, and the prevention, treatment, and care of NCDs lags significantly among the poor compared with wealthier individuals. While poverty-related causes remain relevant in many countries, major societal trends, including an accelerated movement away from rural and toward urban living, increased international mobility, and enhanced global trade, are exacerbating many of the known risk factors. Individuals with physical disabilities may have increased risk of developing NCDs like diabetes and cardiovascular disease because of the difficulty they face in finding employment, staying fit, and maintaining a healthful diet.²⁶

The Government of the United States, one of the world’s most important funders of global health programs, has no unified mechanism for supporting work on NCDs in other countries, and many key agencies, such as the US Agency for International Development and the US Department of State, lack any budget authority to support programs in this area. The US Government, through the US Centers for Disease Control and Prevention, the National Institutes for Health, and other agencies, has an important and continuing role in the surveillance, prevention, detection, care, and treatment of these disorders in the United States.¹⁴ Likewise, within the United Nations (UN) there is no agency charged with overall coordination of NCD activities. WHO’s Noncommunicable Diseases and Mental Health Cluster works on standard setting and monitoring of NCDs,¹⁵ but has no role in UN development policy or in field-based interventions.

In order to take note of and act upon at least one alarming global trend on NCDs—the rise in consumption of tobacco products—the UN created the Framework Convention on Tobacco Control (FCTC) in May 2003, to which 172 countries, though not the United States, are now party.²⁷ The FCTC is a systematic framework to reduce global production and consumption of tobacco products around the world. In addition, the UN also convened a high-level session on September 19–20, 2011, devoted to raising awareness about the global threat of NCDs. This is just the second time in its history that the UN General Assembly has addressed a global health topic—the first was for HIV/AIDS in 2001.^7,8,28

Many, though not all, deaths from NCDs are preventable. WHO estimates that with adequate action, 4 of 5 deaths from heart disease, stroke, and type 2 diabetes, as well as a third of all occurrences of cancers, could be averted by eliminating or reducing tobacco and alcohol use, eating a healthful diet, and maintaining appropriate levels of physical activity.^7,8,15,28,29 There is ample evidence that increasing peoples’ “health literacy” can prevent much illness, death, and massive loss of productivity.¹⁴ NCDs resulting from unhealthy living conditions could be decreased by better integrated health care, a focus on poverty alleviation, more attention paid to over- and undernutrition and the contribution of processed and industrialized foods (instead of the more traditional ones),^30–34 and a reduction in cooking- and heating-related indoor air pollution. There are important gains to be had in stopping or treating some infections (such as from human papillomavirus) before they become chronic illnesses (such as cervical cancer).^7,8,35

The costs of inaction are staggering, not only because of the skyrocketing price of treating those with chronic illnesses but also because of the billions in productivity that NCDs sap from economies large and small.^18,20,22,29 Yet a recent study by the University of Washington’s Institute on Health Metrics and Evaluation concluded³⁶ that the percentage of development assistance for health spent on NCDs was less than 1% (others have calculated this as less than 3%³⁷). In addition, WHO notes that many countries, even those with heavy disease burden from NCDs, lack adequate surveillance mechanisms to take account of illness prevalence and trends.^7,8

There is scope for US leadership on reducing the global burden of NCDs, given the experience the US-based public health community has in preventing NCDs and caring for those living with them.^15,38 As we continue to fight NCDs in our own country, we should commit to building proven principles of NCD prevention into US foreign assistance, including those related to global health, especially when nations request this of us. We should be willing to share what the US public health community—the government, private sector, nongovernmental organizations, and academia—know about effective NCD prevention, treatment, and care. We should ask our government to work on our behalf collaboratively with donor and recipient nations to build systems that monitor relevant data, so that culturally and linguistically appropriate interventions can be implemented with integrated approaches to prevention, treatment, and care, and the results measured and evaluated. And we should express our desire that global institutions, including the UN, develop adequate systems for assessing the scale of and alleviating the NCD epidemic.

Proposed Recommendations Statement

In order to more fully address the growing epidemic of noncommunicable diseases in less-developed countries, as well as to account for the continuing need to address NCDs in the United States, APHA and its members should—

• Acknowledge that the leading causes of mortality, associated with more than 43 million deaths per year, are NCDs—namely, cardiovascular disease, lung disease, cancers, and diabetes; 
• Note that many other conditions, including injuries (such as from road traffic accidents), mental illness, and birth defects, are significant additional causes of morbidity and mortality;
• Take into account that many of these deaths and illnesses are preventable;
• Acknowledge the social determinants and poverty-related causes and exacerbations of NCDs;
• Create and maintain relevant training for public health practitioners to help address the global epidemic of NCDs, especially among the poor, children, women, older adult populations, people with disabilities, people residing in rural or other isolated settings, medically underserved groups, and other vulnerable groups who are likely to experience health disparities.

Moreover, APHA urges governments, including the United States Government, to—

• Fully account for mortality and morbidity associated with noncommunicable diseases in every country through comprehensive disease surveillance;
• Develop national frameworks and action plans to integrate noncommunicable disease prevention into existing and new public health, global health, and development efforts, particularly for surveillance, research, prevention, care, and treatment;
• Create systems and programs for addressing known risk factors, including consumption of alcohol and tobacco, overconsumption of salt, obesity, lack of adequate physical exercise, disabilities, exposure to indoor air pollution, and unsafe roadway conditions;
• Ratify and work to implement the UN FCTC;
• Create incentives for all elements of civil society, including the private sector, to form a coordinated response to the NCD epidemic;
• Provide the most robust possible funding for these efforts at national and international levels.

APHA also asks the UN to—

• Develop appropriate standards through WHO for the surveillance, prevention, detection, treatment, and care of NCDs;
• Create programs through development agencies such as the UN Development Program, the UN Children’s Fund (UNICEF), UN Women, the UN Population Fund (UNFPA), and the UN Environment Program that directly address poverty and the social determinants of health;
• Develop a mechanism for coordinating all NCD-related activities throughout the UN system.

Finally, APHA urges international and domestic for-profit and nonprofit organizations to— 

• Engage all elements of society in surveillance, prevention, care, and treatment of NCDs, including faith-based organizations, academic institutions, for-profit corporations, nonprofits, governments, and foundations;
• Acknowledge the role and responsibility of systems that produce and promote alcohol, tobacco, and high-calorie low-nutrition foods, including those marketed and distributed globally, to create healthier alternatives.

References

1. American Public Health Association. APHA Policy Statement 9101: Childhood Asthma: A Major Public Health Problem. 1991. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=8. Accessed December 20, 2011. 
2. American Public Health Association. APHA Policy Statement 9202: The Prevention of Diet-Related Chronic Diseases. 1992. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=53. Accessed December 20, 2011.
3. American Public Health Association. APHA Policy Statement 20038: Supporting a Nationwide Environmental and Health Tracking Network to Identify Links Between the Environment and Human Health. 2003. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1244. Accessed December 20, 2011.
4. American Public Health Association. APHA Policy Statement 200615: A Call for a Framework Convention on Alcohol Control. 2006. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1339. Accessed December 20, 2011.
5. American Public Health Association. APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries. 2008. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1375. Accessed December 20, 2011.
6. American Public Health Association. APHA Policy Statement 20094: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health. 2009. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1388. Accessed December 20, 2011. 
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