The UN’s Battle With NCDs

The World Health Organization (WHO) calls it an "invisible epidemic." In the United States and now many parts of the developing world, the biggest killers are no longer infectious diseases, such as HIV and AIDS or malaria, but rather chronic conditions, such as heart and lung disease, cancer, and diabetes. Often the preventable result of unhealthy diets, tobacco, and alcohol use and a lack of physical activity, these non-communicable diseases, or NCDs, now account for two out of every three deaths worldwide.

Most surprising, perhaps, is that NCDs have rapidly gone from afflictions of the developed world to afflictions of the developing world. "Very many unhealthy habits have crept in," says Troy Torrington, of Guyana's mission to the United Nations. Those include a lack of exercise, the consumption of junk food, and the use of alcohol and tobacco promoted by aggressive sales and marketing campaigns. In sum, the lifestyles of people in the developing world are becoming more like those in the United States. This is not just an individual, or even a government-level, health issue. There is a global concern as well: The World Economic Forum has identified NCDs as one of the top threats to worldwide development, as they are driving up health-care costs, disabling workers, and exacting debilitating financial tolls on households.

Although the fight against AIDS, tuberculosis, and malaria has attracted rock-star advocates and billions of dollars in funding in the past decade, efforts to fight NCDs are much less visible. According to a recent report, less than three percent of the nearly $22 billion spent in 2007 on global development assistance for health was dedicated to NCDs. If this week's high-level UN meeting on NCDs is any indication, that is unlikely to change anytime soon. A hard look at the negotiations that made the meeting in New York possible is a study in the way politics, commerce, and science can combine to influence global health policy in a difficult economic climate. The question is whether an approach that favors partnership with industry over regulation and that kicks the can forward on monetary commitments and specific targets to reduce the toll of NCDs will end up making as much of a difference.

The priorities of multinational corporations were key sticking points in discussions over the meeting's pre-negotiated political declaration, which includes the commitments that world leaders are expected to make on behalf of their nations. The negotiations took unexpectedly long and briefly broke down over the summer before the countries reached consensus about two weeks prior to the meeting. According to several attendees, the U.S., Canada and the European Union -- along with several other developed countries -- generally opposed setting immediate targets for reducing the prevalence of NCDs and resisted explicit calls for taxation on unhealthy products, industry regulation, and patent exemptions to lower drug prices.

Instead, negotiators for these countries pressed for commitments to voluntary action; partnership with the private sector; fostering research and technology innovations to develop better diagnostics, treatments and methods to reformulate foods and beverages; and an emphasis on expertise sharing, especially from the United States, which has been successful in reducing risk factors, including for smoking. In the end, this approach won out.

It stands to reason that corporations would have a serious interest in the decisions coming out of today's meeting. Officials from the food, beverage, alcohol, pharmaceutical, and tobacco industries could either gain or lose significant future global growth depending on the outcome.

Some public health advocates, including Ann Keeling, the chair of the NCD Alliance, a leading organization made up of diabetes, heart, cancer and lung disease advocacy federations, were critical of the United States and other wealthy countries' positions. Keeling said during the stalled negotiations that it would be a "waste to have convened a meeting at this level" without time-bound commitments to form the basis of an action plan. However, U.S. officials argue that working in partnership with industry, along with nongovernmental organizations, and allowing more time to develop specific targets will lead to better results in the fight against NCDs in the long run.

This battle dates to the 1990s, when public health researchers found that NCDs had eclipsed the lethality of infectious diseases in most parts of the world. The WHO reorganized its Geneva offices to direct more attention to the issue and initiated a highly successful UN convention on tobacco control. Still, the multibillion-dollar commitments from wealthy nations to prevent and treat HIV/AIDS, tuberculosis, and malaria in the developing world remained the top agenda item for donor nations. "What we were doing," said Babatunde Osotimehin, the executive director of the UN Population Fund, at a recent Council on Foreign Relations meeting on NCDs, "was to put the communicable disease in a silo as if that's all we had to deal with." Meanwhile, he argued, years passed without much being done to strengthen health systems for what was inevitable, the current flood of NCDs.

During the negotiations leading up to the UN meeting, the toughest disagreement, according to several people who attended the sessions, was over whether NCDs should be referred to as an epidemic and a public health emergency. The decision is about more than rhetoric. Such a designation could allow countries to invoke flexibilities in World Trade Organization rules that permit manufacturers to make cheaper generic versions of patented drugs needed to protect the public's health. Developing countries with large generic drug industries clearly favored the move. Washington, of course, opposed the measure, a view clearly in line with the interests of its large pharmaceutical industry.

"The challenge was whether simply doing away with patent protections on all drugs that treat non-communicable diseases is the right course," says Nils Daulaire, the director of the Office of Global Affairs at the U.S. Department of Health and Human Services. "That, to our minds, was not the way you get a stream of ongoing research and development and the new and improved drugs that we continue to need."

Some pharmaceutical and medical device companies have also become deeply involved in bankrolling the campaign against NCDs, even paying for messages about the high-level meeting on public radio and underwriting a Washington Post forum on the subject that was covered by the newspaper last week. Among the "civil society representatives" the UN invited to participate in the high level meeting are drug makers with a large U.S. presence, including GlaxoSmithKline Oncology, Sanofi Aventis, and Varian Medical Systems.

While the NCD Alliance differed with U.S. officials on the issue of time-bound commitments, it shared the U.S. position on protecting patents. The NCD Alliance is supported by close to a dozen major pharmaceutical and medical device companies, and Keeling says that many important drugs used to treat non-communicable diseases are already off patent and available in generic form, including insulin, blood pressure medications, and morphine to palliate cancer pain. "We still think it's possible to save tens of millions of lives using the drugs we already have," Keeling says.

The common view in the developing world was different. "Particularly with cancer, a lot of the medications are just not accessible or affordable," says Guyana's Torrington, who negotiated on behalf of a block of 132 low- and middle-income countries and China. Ultimately, the negotiators reached a compromise that called NCDs "a challenge of epidemic proportions" and allowed inclusion of oblique references to flexibilities in the current international trade agreement on intellectual property. While that is far from an outraged call to break patents, it serves as a reminder that existing trade law allows for public health exceptions and compulsory licenses to produce generic medications.

At issue, too, was the best approach to deal with companies that produce alcoholic beverages or other food and beverages high in salt, sugar, and unhealthy fats. Companies such as Anheuser-Busch InBev and Molson Coors Brewing Company were also invited to participate in the meeting as civil society representatives. PepsiCo is sponsoring events for delegates, and its corporate officials will actively participate in the meeting through organizations such as the United Nations Business Council and the International Food and Beverage Alliance. One of PepsiCo's officers, Derek Yach, who formerly served as the executive director of the WHO, says PepsiCo was already working to reformulate products, promote a shift to healthier oils by growers, and had voluntarily committed to reducing salt in major brands by 15 percent. Financial resources and technical know-how of engaged companies, he argues, could help bring about the changes that public health advocates desire with less cost to governments than a regulatory approach would entail.

Yet Keeling maintains that voluntary action alone will not ensure sustained reforms and accountability from industry. "We believe governments will have to go beyond voluntary changes and it will have to be a matter of regulation," she says. For their part, U.S. officials say they are taking a pragmatic approach. "The question is whether this is done through fiat or whether it's done through mechanisms that involve working with the private markets," Daulaire says. "It's unrealistic to think a UN declaration by itself will have the impact of reducing salts."

And then there is tobacco. Public health researchers say that tobacco is responsible for the most preventable NCD-related deaths. Through a series of public health and regulatory efforts, the United States has witnessed a dramatic decline in smoking at home. Many advocates would like to see the United States devote more resources to tobacco control programs overseas. "The U.S. government spent $8.4 billion on global health and less than $7 million on international tobacco control despite tobacco being responsible for more deaths than HIV, TB, and malaria combined," says Thomas J. Bollyky, a senior fellow for global health, economics, and development at the Council on Foreign Relations.

Tobacco companies, which make products that public health experts agree cannot, in any way, be used safely, are not on the list of official meeting participants, although they could lobby the UN country delegates who decided the meeting's results. According to those present at the negotiations, some tobacco-producing countries in the developing world successfully fought the expansion of tobacco taxation, which could not only decrease smoking but also provide a key source of revenue for states to fund other disease prevention and treatment programs.

Will today's meeting make a difference? Representatives of the United States and other major global health donors have said they will not commit significant new resources to fight NCDs or divert their attention from current global health priorities. "We don't feel there should be cuts for maternal and child survival, AIDS, immunization programs, or the control of pandemic diseases," says Daulaire. "The U.S. Congress has made it crystal clear: Budgets will not be increased, they will be reduced."

By all indications, the breathtaking advances made in AIDS treatment in developing countries are unlikely to be replicated here. However the very fact of the UN meeting and the controversies in its run-up are clear evidence not only of the worsening global affliction, but that major players -- in both capitals and boardrooms -- around the world are taking note. The subject has space reserved on the global agenda, as a comprehensive UN review is planned for 2014. 

The fact that NCDs are expected to weigh more and more heavily on the developing world, including some of the world's most powerful emerging markets, in the coming decades may leave governments little choice but to address their causes and management. It is becoming clear that steps taken now could save both lives and money in the future.