So, What was Accomplished? The UN and NCDS
You couldn’t possibly have picked a worse time to convene a high level United Nations meeting on a problem whose solutions require spending $11.4 billion annually and confronting some of the most profitable industries in the world: Tobacco, pharmaceuticals, processed foods, soda pop, and chain eateries. The timing of this week’s High Level Summit on Noncommunicable Diseases could only have been more poorly chosen if it coincided with Great Depression II. As it is, the Great Recession, and efforts to forestall said depression, guaranteed that any discussion of added expenditures to the already crowded global health and development agendas, or confrontation of “job creating” industries was politically impossible. In his remarks to the United Nations this week President Barack Obama made no mention of the NCD Summit, nor any direct references to global health issues of any kind. The September 20 Fact Sheet from the White House, issued to reporters at the Summit, also omits any references to NCDs, though it does refer to “Global Health Security.”[i] Even the typically generous Scandinavians scoffed at efforts to set donor and action targets for handling diabetes, cancer, heart disease and other noncommunicable health issues at the General Assembly level.
After months of haggling, millions of dollars’ worth of meetings and travel costs and a prodigious mountain of studies and documents prepared in anticipation, the final Declaration of the UN High Level Meeting is little more than a wishy-washy rendition of problems and vague solutions that are obvious to even casual observers of the tidal shifts in global demography. (Super-insightful global health reporter Tom Paulson offers a similar assessment. Pulitzer Prize-winning reporter Sheri Fink and Rebecca Rabinowitz also echoes many of these points.) The good news: populations the world over – in rich and poor countries, alike – are living longer, and public health interventions to halt mortality due to infectious diseases are paying off. Fewer children every year are dying of measles, diarrheal diseases, or pneumonia; more adults are living to ripe old ages fraught with cancer, strokes, heart attacks, diabetic kidney failure, dementia, and other chronic ailments that typically afflict individuals in their sixth decades of life, or beyond. As the declaration painstakingly details every chronic disease problem is, in numeric as well as per capita terms, increasing.
From the moment two years ago that the CARICOM Caribbean nations proposed the NCD summit the multilateral agencies and giant NGOs that deal with things like cancer and heart disease recognized a mixed blessing. On the one hand, there was opportunity to call attention to the pitiful state of prevention and treatment of such maladies in poor and emerging market countries. Even behemoth economies such as China and Brazil remain hard-pressed to provide their populations with decent treatment for malignancies, juvenile-onset diabetes, schizophrenia, atherosclerosis or any other life-threatening disorder that requires prolonged interventions and highly skilled personnel for proper diagnosis and treatment. For the approximately 2 billion people in poorer countries cobalt treatment may result in radiation burns due to badly calibrated machinery, pain management for end-stage cancer is likely to be limited to a single daily drip of morphine, and coronary surgery is only available to the upper 1 percent of the population.
It was therefore heartening to many advocacy groups and international health agencies to have an opportunity to call attention to the desperate state of medical management of such diseases for most of the world’s population. Few residents of Planet Earth can hope to have bypass surgery in Dallas, cancer treatment at Harvard, or annual check-ups at the Mayo Clinic. In truth, few Americans can dream of such possibilities, particularly the approximatelty 50 million that currently lack health insurance.
But the same entities that hailed the opportunity to highlight these issues recognized that the only realistic theme for the Summit was prevention. As Americans are painfully aware, the United States cannot now provide multiple bypass surgery to all citizens that have failing cardiac function, as it is too expensive. Preventing that cardiac failure is the more affordable, preferred option. But preventing HIV infection through condom use is a tough-enough behavior modification sell; getting the world’s population to lower salt and sugar intake, stop consuming trans-fats, execute daily aerobic exercise, cease all forms of tobacco use, moderate alcohol intake, wear seatbelts in vehicles, eat sufficient amounts of vegetables, lower red meat consumption – well, you get the idea.
What the NCD Declaration avoids recognizing is that the behaviors that are putting increasing numbers of human beings at risk for most such diseases have strong lobbies behind them, with enormous financial fire power. The industries are well known. At the top of the list of obvious contributors to world chronic disease is the tobacco industry, and the number one producer of cigarettes in the world is the Chinese People’s Liberation Army, followed closely by American, British and French tobacco companies.
Perhaps the best speech delivered to the Summit came from New York City Mayor Michael Bloomberg, a politician and billionaire that has staked a large claim in the public health arena. He could very justifiably brag to the UN delegates, as under his leadership New York has dramatically reduced nearly all forms of mortality among its residents, increased life expectancy, and made the metropolis one of the healthiest urban place to live in the United States. These achievements were made through highly controversial exercises of legal authority, banning virtually all forms of public smoking (even outdoors), commanding eateries to post calorie counts and eliminate all forms of trans-fats in their foods, confronting the soda pop industry and reducing sugared drink distribution in schools, adding hundreds of miles of bike and running paths all over the city, dramatically improving general population access to basic screening tests for cancers, and making condom use hip and cheap.
“In today’s world, healthy solutions are not necessarily costly solutions,” Bloomberg told the UN summit. “Far from it. New York’s Smoke-Free Air Act, our restrictions on trans-fats, and our requirements concerning calorie posting in restaurants cost virtually nothing in public money to put into effect. And cigarette taxes raise public revenues.”
Few political leaders are prepared to directly confront the business interests responsible for unhealthy eating and behavior, as Bloomberg has. Apparently politicians’ timidity is mirrored by the United Nations General Assembly and the gamut of UN agencies. A group of global NGOs warned on the eve of the gathering that conflicts-of-interest with highly profitable industries could sink the entire UN process.
The Declaration ultimately fails because it calls for a sort of global mass behavior modification effort without naming the culprits responsible for mass addiction to nicotine, excessive sugar, excessive trans-fatty oils, excessive salt, excessive raw calories, excessive fatty meats, deficient fruits and vegetables, and promotion of sedentary lifestyles in which passive entertainment replaces exercise and sports. Because the declaration is timid, polite and vague, it fails. The industries that profit from disease are let off scot-free, unnamed other than three allusions to the tobacco convention.
The only industry that comes under attack in the Declaration, albeit quite mildly, is pharmaceuticals. In advance of the UN summit many NGOs lobbied hard for direct attack on pharmaceutical patents, arguing that freeing medicines from high patent-protected pricing would save millions of lives from heart attacks and cancer. Every global health discussion these days, regardless of the topic, seems to boil down to a debate between the intellectual property provisions of the World Trade Organization versus access to cheaper, generic drugs. In the context of noncommunicable diseases this is an odd fight, as few poor and even emerging market countries have steady supplies of the 100% NON-patented WHO Essential Drugs and Medicines inventory.
The existence of a flourishing generics industry for antibiotics, basic cancer chemotherapy, many statins, cardiovascular therapies, and a broad range of psychoactive drugs has not translated into access to those vital medicines for most of the world’s populations. Either the medicines, even in India or China-made generic form, remain too expensive, or more typically supply chains for their purchase and distribution are broken or nonexistent. Inside the U.S. we now face unprecedented shortages of vital life-saving medicines, especially cancer chemotherapy. In some cases all manufacture of long-off-patent products is the issue, while in others it is price-gouging that has absolutely nothing to do with patents. According to Mike Alkire, chief operating officer of Charlotte-based Premier healthcare alliance, “the vast majority of hospitals nationwide are experiencing life-threatening shortages of medicines. Similar to 2008, price gougers are selling scarce medicines at obscene prices. In one case, a hospital reported a blood pressure medication that normally sells for $25.90 being offered for $1,200 - a 4,533 percent markup. Mark-ups have been as high as 3,980 percent for chemotherapy medicines to treat leukemia, and 3,170 percent for medicines to help cancer patients retain bone marrow. These aren't rare examples. Hospitals nationwide report being asked to pay an average of 650 percent above normal prices for shortage items."
Despite loudly-shouted willingness to purchase said drugs from any manufacturer, large or small, hospitals and physicians are learning that lack of profitability leads both generic and patented pharmaceutical makers to abandon entire lines of essential medicines.
In her remarks at the Summit WHO Director-General Dr. Margaret Chan warned delegates, “Watch out. Even an old dog like the tobacco industry can learn some dirty new tricks.” Several countries announced new regulations on tobacco sales, trans-fat foods and salt levels in processed commodities, indicating the New York City lessons have resonated. Even if there are no teeth in the Declaration, a few governments on each continent appear ready to put a bite on promotion of unhealthy, addictive products.
Kenya, for example, is setting limits on the food and tobacco industries that replicate some of the New York City achievements. But the country is struggling to balance the tremendous financial burdens of TB, HIV and malaria – all at epidemic proportions in the east African nation – against its rising load of chronic disease. This balancing act, in a time of resource scarcity and recession, is a common theme throughout Africa and much of the rest of the developing world.
One of the most hopeful trends in Global Health today is integration of acute and chronic services where it makes solid sense. In one of the UN side sessions this week, “Achieving health equity: united around a common agenda to address NCDs and HIV,” leaders of the fight against AIDS committed to dramatically improving access to general reproductive health services and cervical cancer diagnosis and treatment. Recognizing that a woman seeking an HIV test is likely to have been exposed to the human papilloma virus, which causes cervical carcinoma, leaders agreed that she should have a pap smear along with her HIV test. Indeed, the trend is towards provision of packages of basic services that combine attention to infectious and noncommunicable diseases. That woman seeking a pap smear or HIV test ought to also be taught how to perform breast cancer self-examination, and her male counterpart should be worked up for not only a full range of sexually-transmitted infections, but also prostate cancer, hypertension, blood sugar levels, and other basic health markers.
Similarly, the expanding health agenda, taxed by diminishing global financing, is forcing radical new thinking regarding efficient ways to combine health services, and financing models. Among the schemes gaining the most attention are those that seek to combine public and private insurance/voucher/government subsidies to produce universal health coverage (UHC). The goal of UHC is to eliminate the bankrupting impact on families of major illness, thereby both providing access to health care and reducing its larger costs to society, as a whole.
For example, data released by the U.S. Census Bureau last week shows that the United States now has more people living in official poverty than at any time since 1997. So many Americans have lost their jobs that only half the population is now covered by employer-based health plans, the primary way health coverage in the U.S. was available over the last 60 years. Nearly a third of the under-66-year old population is now dependent on government-provided coverage, and a shocking 50 Million people have no health coverage at all --- they are too “rich” or too young to qualify for government Health Coverage, and too poor to purchase private insurance.
An official government term in the U.S. – “medical debt” and its horrible companion term “medical bankruptcy” are now featured in Census reports. Medical debt is a key contributor in 62% of all personal bankruptcy filings in the U.S. including among people that have insurance coverage, but with plans that require such high co-payments that for 161 million Americans long term chronic disease management, cancer, heart disease or major trauma injuries are bankrupting events. Every year worldwide 100 million people are pushed into dire medical debt.
Few health issues demonstrate the need for innovative financing schemes as clearly as the race to meet the maternal health provisions of the Millennium Development Goals. At this time only nine out of 137 targeted countries are on track to meet the maternal survival MDG, in large part because most of the women in the developing and emerging market world are unable to afford, or simply have no infrastructural access to, 24/7 obstetric healthcare.
The $11.4 billion annually that WHO thinks could allow a decent fight against NCDs worldwide is a paltry sum compared to the $15.9 billion spent in 2010 on HIV/AIDS, alone. The most common phrase I heard mumbled around the NCD Summit was, “We have to learn from the HIV movement. We have to adopt their tactics to raise money.” The comment is ludicrous, as no issue can possible replicate the experience of the 30-year battle against a newly emerging pandemic, fought largely by men and women who were either infected or members of a highly-infected community. The urgency and take-no-prisoners posture of the HIV fight is utterly unique.
Worse, even the successes of HIV/AIDS advocacy are now in peril.
Donor commitments to global health generally, and HIV/AIDS specifically are falling like dominoes as Europe looks inward to the survival of the euro and the United States descends deeper into its rhetorical civil war. Worse, the primary innovation in HIV funding is under sharp attack. On the eve of the NCD Summit “The Final Report of the High-Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria” – a cumbersome title if ever there was one – was released. It’s a very grim read. The independent review panel, co-chaired by former Botswana President Festus Mogae and former U.S. Secretary of HHS Michael Leavitt, found that, “a combination of economic distress among donor nations and the OIG reports that prompted the creation of this review imperil the sustainability of the Global Fund more than the organization has acknowledged. A new economic reality, new technologies, and new epidemiological patterns compel the Fund to adjust, and it must reform itself to remain relevant. Three large trends will force the Fund to change: austerity, accountability and innovation.”
Money is not well accounted for, the review panel charged. And, “The Panel has found that the culture of the Global Fund has become one driven by the measurement of documentation, and not by health impact.”
As the Global Fund struggles to redefine itself, heading from acting as an emergency epidemic responder to a sustainable manager of global chronic disease, it may find greater solidarity with the older battles against cancer, diabetes, heart disease, and the like.
In the end, the greatest outcome of the NCD Summit may be the sobering recognition that the Global Health movement has lost its way, and must urgently identify strategies and targets appropriate to a time of financial doom, combining efforts, integrating services, and looking to the holistic needs of people all over the world.
[i] The White House paragraph on Health Security: “The United States has taken a multi-faceted approach to dealing with infectious diseases, whatever their cause, through fora such as the UN Security Resolution 1540, the Biological Weapons Convention (BWC), and World Health Organization (WHO). The BWC Review Conference in December offers an important opportunity to revitalize international efforts against these threats, helping to build global capacity to combat infectious disease, and prevent biological weapons proliferation and bioterrorism. This week the United States is signing an agreement with the WHO on “Global Health Security,” affirming their shared commitment to strengthen cooperation on common health security priorities. Improving global capacities to detect, report and respond to infectious diseases quickly and accurately lies at the heart of the WHO’s International Health Regulations. The U.S. is committed to have in place these vital IHR core capacities as soon as 2012.”