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<h2 style="margin-right:0in;margin-left:0in;font-size:18pt;font-family:"Times New Roman";font-weight:bold">WHO Consultations on a monitoring framework and targets for the
prevention and control of non-communicable diseases<span> </span><span></span></h2>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">Latest WHO -meeting covering noncommunicable diseases: EB130 <b><font size="4">January 2012</font></b> -
agenda item 6.1: Prevention and control of non-communicable
diseases. Click <a href="http://www.ghwatch.org/sites/www.ghwatch.org/files/WHO%20EB%20130-MMI%20PHM%20statement%20on%20NCDs.pdf" style="color:blue;text-decoration:underline">here</a>
for the <b><span style="font-size:16pt">statement
made by PHM </span></b>or read below.<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""> <span></span></p>
<h2 style="margin-right:0in;margin-left:0in;font-size:18pt;font-family:"Times New Roman";font-weight:bold">Background: The challenge of non-communicable diseases<span></span></h2>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">Non-communicable diseases (NCDs), principally cardiovascular diseases,
diabetes, cancers, and chronic respiratory diseases, are the leading causes of
death globally, killing more people each year than all other causes combined.
NCDs caused an estimated 35 million deaths in 2005. This figure represents 60%
of all deaths globally, with 80% of deaths due to non-communicable diseases
occurring in low- and middle-income countries. About one fourth of global
NCD-related deaths take place before the age of 60. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The combined burden of these diseases is rising fastest among lower-income
countries, populations and communities, where they impose large, avoidable
costs in human, social and economic terms. Patients and their families are
pushed into poverty because of catastrophic health expenditures and countries
are spending a large part of their health budget on chronic conditions. A
recent <a href="http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf" style="color:blue;text-decoration:underline">Harvard
University study</a> estimates that over the next 20 years, non-communicable
diseases will cost the global economy more than $30 trillion, representing 48
per cent of the global GDP in 2010. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">Total deaths from non-communicable diseases are projected to increase by a
further 17% over the next 10 years. The rapidly increasing burden of these
diseases is affecting poor and disadvantaged populations disproportionately,
contributing to widening health gaps between and within countries. Despite
their rapid growth and inequitable distribution, much of the human and social
impact caused each year by NCD-related deaths could be averted through
well-understood, cost-effective and feasible interventions.<span></span></p>
<p class="gmail-msonospacing0" style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The four ‘major’ NCDs - cardiovascular diseases, chronic
respiratory diseases, diabetes and cancer - are caused to a large extent, by four
behavioural risk factors that are pervasive aspects of economic
transition, rapid urbanization and 21st-century lifestyles: tobacco use,
unhealthy diet, insufficient physical activity and the harmful use of
alcohol. The greatest effects of these risk factors fall increasingly on
low- and middle-income countries, and on poorer people within all
countries, mirroring the underlying socioeconomic determinants. Among
these populations, a vicious cycle may ensue: poverty exposes people to
behavioural risk factors for NCDs and, in turn, the resulting NCDs may
become an important driver to the downward spiral that leads families towards
poverty. As a result, unless the NCD epidemic is aggressively confronted
in the most heavily affected countries and communities, the mounting
impact of NCDs will continue and the global goal of reducing poverty will
be undermined.<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">As the magnitude of the NCD epidemic continues to accelerate, the pressing
need for stronger and more focused international and country responses is
increasingly recognized by Member States. Since the WHO Secretariat
presented its <a href="http://apps.who.int/gb/archive/pdf_files/WHA53/ea14.pdf" style="color:blue;text-decoration:underline">Global
Strategy for the Prevention and Control of Non-communicable Diseases </a>to the
World Health Assembly in 2000, many resolutions on the topic were adopted and
many meetings held, most recently the <a href="http://www.ghwatch.org/node/633" style="color:blue;text-decoration:underline">High-level
Meeting of the United Nations General Assembly on the Prevention and Control of
Non-communicable Diseases</a>. We have prepared a <a href="http://www.ghwatch.org/sites/www.ghwatch.org/files/NCDs_HistoryInternationalPolicyDeclarations.pdf" style="color:blue;text-decoration:underline">presentation</a>
which provides an overview of all the relevant resolutions, documents and
political declarations. It also summarizes the aspects of relevance for members
of the PHM, focusing on what has been said on the social determinants of
health, access to medicines, integration, sustainable financing and
accountability.<br>
<br>
<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">However, despite abundant evidence of their negative impact, policy-makers
still fail to regard NCDs as a global or national health priority. Incomplete
understanding and persistent misconceptions continue to impede action. Although
the majority of NCD-related deaths, particularly premature deaths, occur in
lowand middle-income countries, a perception persists that NCDs afflict mainly
the wealthy. Other barriers include the point of view of NCDs as problems
solely resulting from harmful individual behaviours and lifestyle choices,
often linked to victim ‘blaming’. The influence of socioeconomic circumstances
on risk and vulnerability to NCDs and the impact of health-damaging policies
are not always fully understood; they are often underestimated by some
policy-makers, especially in non-health sectors, who may not fully appreciate
the essential influence of public policies related to tobacco, nutrition,
physical inactivity and the harmful use of alcohol on reducing behaviours and
risk factors that lead to NCDs. Effective interventions, such as tobacco control
measures and salt reduction, are not implemented on a wide scale because of
inadequate political commitment, insufficient engagement of non-health sectors,
lack of resources, vested interests of critical constituencies, and limited
engagement of key stakeholders.<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">Reducing exposure to the risk factors for NCDs and their determinants is
also not enough. Improved health care, early detection and timely treatment is
another necessary aspect of reducing the impact of NCDs. However, appropriate
care for people with NCDs is lacking in many settings, and access to essential
technologies and medicines is limited, particularly in low- and middle-income
countries and populations. Health systems need to be further strengthened to
deliver an effective, realistic and affordable package of interventions and
services for people with NCDs.<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">We need to change the way policy-makers perceive NCDs and their risk
factors, and how they then act. Concrete and sustained action is essential to
prevent exposure to NCD risk factors, address social determinants of disease
and strengthen health systems so that they provide appropriate and timely
treatment and care for those with established disease.<br>
<br>
Sources: <br>
WHO Global Status Report on Non-communicable Diseases<br>
WHO 2008-2013 Action Plan on the Global Strategy for the Prevention and Control
of Non-communicable Diseases<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong><span style="font-size:13.5pt">PHM analysis of the international
response to NCDs</span></strong><span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><em>"The policies that promote unhealthy lifestyles throughout entire
populations are made in domains beyond the direct control of health. For many
decades, public health has stressed the need for collaboration with other
sectors, especially for prevention. For a very long time, these were friendly
sectors, almost sister sectors, like education, the environment, water supply,
sanitation, and a secure and safe food supply. Today, many of the threats to
health that contribute to noncommunicable diseases come from corporations that
are big, rich and powerful, driven by commercial interests, and far less
friendly to health</em>"<br>
<br>
Dr Margaret Chan, Director General of WHO [1]<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The most important message concerning non-communicable diseases is that the
factors that shape the NCD epidemic lie outside the reach of health policy so
that most health gains in terms of prevention will be made by influencing
policies in domains such as trade, food and pharmaceutical production,
agriculture, urban development, and taxation policies[2]. Addressing NCDs thus
requires a Health in All Policies approach to enhance accountability for health
in other sectors; an approach that can further promote health equity and more
inclusive and productive societies [3]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The global response is hugely disappointing in this regard. While the
importance of the social, economical, political and environmental determinants
of health and the need for multisectoral action is recognized in every document
you can find, global action is geared towards interventions to change
individual health behaviours and multisectoral action is understood as
establishing partnerships with industry. The current global response framework,
the 2008-2013 Action Plan for the Global Strategy Global Strategy for the
Prevention and Control of Non-communicable Diseases [4] focuses on 'four
diseases and four risk factors'; and has eliminated action on the social
determinants of health in its objectives (1). Within the international
community, NCDs are still too much viewed as problems solely resulting from
harmful individual behaviours and lifestyle choices, often linked to
victim-blaming, and the influence of socioeconomic circumstances on risk and
vulnerability to NCDs and the impact of health-damaging policies are
underestimated [2]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>The 'four diseases and four risk factors'-framework fails to address
the causes of NCDs</strong>. The strategy of identifying risks and expecting
individuals to change their behaviour to minimize their exposure has proved
inadequate. Genuine choice and an ability to modify risks depend on living
conditions and access to resources [5]. This point was stressed by Princess
Dina(Union for International Cancer Control) in her opening speech at the UN
High-Level Meeting on NCDs in September 2011:<em> "lifestyle changes, as
they are called, give the impression that it is a matter of choice or
preference. But when unhealthy foods are more affordable than healthy ones,
when tobacco, which kills, is so easily accessible, and when facilities or
space for exercise are non-existent, it becomes not a lifestyle choice but a
life sentence" </em>[6].<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The Action Plan does not recognize the varying contributions of the
identified risk factors to the global NCD burden and will thus not be able to
respond to the different needs of people around the world, especially the most
vulnerable ones. Looking at tobacco use as the risk factor for chronic
obstructive pulmonary disease (COPD), it is crucial to realize that the causes
for COPD have opposite patterns according to the geographic areas. In high- and
middle-income countries tobacco smoke is the biggest risk factor, meanwhile in
low-income countries exposure to indoor air pollution, such as the use of biomass
fuels for cooking and heating, causes the COPD burden (...) <strong>The most
poor women in the world do not get COPD from smoking, but from bad living
conditions</strong> [7]. Averting these deaths will not be done by tobacco
control, but by ensuring access to clean fuel, housing strategies etc. Such a
social determinants approach further has a greater potential return on NCD
prevalence, health and social equity [8]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">There is an urgent need to devote more attention to the <em>structural</em>
determinants of health, such as international trade and financial policies. In
his article on international trade and NCDs, Labonté points out that trade,
despite bringing potential health benefits through economic growth, is one of
the major driving factors of a growing chronic disease burden [9]. Current
attention towards the role of globalization and trade in the spread of risk
factors for chronic diseases however is geared towards interventions to change
health behaviours and on voluntary corporate responsibility. Labonté stresses
the need for a more concerted approach to regulate trade-related risk factors
and thus more engagement between health and trade policy sectors within and
between nations. He noted that an explicit recognition of the role of trade
policies in the spread of non-communicable disease risk factors should be a
minimum outcome of the September 2011 Summit, with a commitment to ensure that
future trade treaties do not increase such risks. Unfortunately this did not
happen.<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The negligence of the importance of the socioeconomic determinants of health
in shaping the NCD epidemic is further reflected in how the discourse has
shifted from a 'vicious cycle' between poverty and NCDs in the Global Strategy
to a<strong> 'tunnel vision'; on the negative economical impact of NCDs</strong>.
The most prominent message now is that NCDs are threatening macroeconomic
development [10]. This narrowing of the focus was aggravated in a way by
attempts to put NCDs on the development-agenda of the General Assembly, a
success story culminating in the High-Level Meeting in September 2011.
Unfortunately, this has led to a mere focus on how NCDs lead to poverty, with
almost no attention to the ways in which poverty contributes to NCDs (2). <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">In the current NCD discourse, health is regarded simply as an input to
economic growth, a means to an end; and a personal responsibility rather than a
public good. <em>"The victim-blaming strategy fails to have a positive
vision of health and its contribution to society"</em> [11]. As described
by McMichael and Beaglehole, there are constant tensions between the goals of
different policy sectors: "tension persists between the philosophy of
neoliberalism, emphasizing self-interest of marked-based economies, and the
philosophy of social justice that sees collective responsibility and benefit as
the prime social goal" [12]. They rightfully concluded that "the
practice of public health, with its underlying community and population
perspective, sits more comfortably with the latter philosophy". Health has
intrinsic value and is a basic human right, and should therefore be an end of
political and societal activity in itself [13]. It is a trans-national public
good and should be an overarching goal in all policies [11]. However, it does
not seem that states are ready to take the necessary actions on international
trade regimes as this is completely left out of the declaration of the HLM. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>What should be stressed in the case of health determinants and NCDs
is a virtuous cycle and not a vicious one</strong>. In the Action Plan the four
main risk factors are considered together to "highlight potential
synergies in prevention and control", but a social determinants approach
would bring about much more important synergies; not just amongst the different
risk factors, but between NCDs and other global challenges. The aim needs to be
to "implement policies that serve broader societal goals, such as
improving wellbeing and development, which also contribute to tackling non-communicable
diseases" [5]. A virtuous circle is possible whereby improvements in
health and its determinants feedback into each other, providing mutual benefits
[13]. The example of providing women with clean stoves for cooking to prevent
COPD points out one of the most important synergies: <em>mitigating climate
change</em>. WHO recently reviewed the IPCC mitigation strategies in its Health
in the Green Economy Initiative and concluded that "the best climate
solutions address key social determinants of health and inequalities"
[15]. These "best climate solutions" would also help reducing the
burden of NCDs, by their so-called "health co-benefits" [16]. A
report released in 2010 by the Health & Environment Alliance states that a
10% increase in the EU greenhouse gas emissions targets by 2020 (from 20% to
30%) would lead to savings of €10.5 billion to €30.5 billion per year, mostly
by reducing cardiovascular disease, cancer, asthma and other respiratory or
cardiac conditions [17]; exactly the conditions on which the Action Plan
focuses. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>Synergies can also be found in the control of the four 'major NCDs' </strong>and
all the remaining conditions people can suffer from, especially those that take
a chronic course. During consultations in preparation of the UN High-Level
Meeting, NGOs have repeatedly pointed out the unclear boundaries between
communicable and non-communicable diseases and have stressed that we should
draw lessons from the HIV/AIDS epidemic and move away from the vertical disease
approach. Separate global health initiatives or funding mechanisms for vertical
non-communicable disease-specific programmes are unlikely to work. Efforts in
one disease area can be used to strengthen the overall health system, thereby
improving care for other conditions as well [18]. In their in their Political
Declaration coming out of the UN HLM, Heads of State have "noted with concern
the possible linkages between non-communicable diseases and some communicable
diseases, such as HIV/AIDS, and call to integrate, as appropriate, responses
for HIV/AIDS and non-communicable diseases" [19]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">It is striking to see that WHO itself has pointed out the arbitrary
delineation between communicable and non-communicable diseases when it comes to
treatment. In its 2002 Innovative Care for Chronic Conditions (ICCC) Framework,
the term <em>chronic conditions</em> is used, which is said to encompass but to
expand beyond the traditional 'NCDs' to include several communicable diseases
such as TB and HIV/AIDS, as well as long-term mental disorders and ongoing
physical/structural impairments [20]. WHO explains: "when communicable
diseases become chronic problems, the delineation between non-communicable and
communicable diseases becomes artificial and unwieldy". It is emphasized
throughout the framework that all these conditions place similar demands on
patients, families and the health care system and that there are similar and
comparable management strategies effective in addressing them. This means that
the global response should not be about the control of non-communicable
diseases, but about<strong> strengthening health systems to provide quality
care for chronic conditions</strong>. It has been argued that primary health
care, because of its patient-centeredness and community-based approach, is best
positioned to address the challenges of chronic disease prevention and
management [21]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">Another key issue in the treatment of chronic conditions is <strong>access
to essential medicines and social security</strong> to prevent patients and
families to be pushed into poverty. At the UN HLM States decided to
"promote access to affordable, safe, effective and quality medicines and
diagnostics and other technologies, including through the full use of
trade-related aspects of intellectual property rights (TRIPS)
flexibilities" [19]. While emphasizing the need for access to essential
medicines, we also want to urge for caution because of clear interests of pharmaceutical
companies in this issue. We do not need another 'me too' medication to treat
high-blood pressure. Focusing too much on biomedical management diverts
attention and resources away from other essential aspects of chronic disease
care such as education, self-management and developing a health workforce [22].
We therefore urge to include the <strong>rational use of medicines</strong> in
the current policy framework. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The issue of conflict of interest of the pharma industry points out the <strong>necessity
to have a reflection on the 'partnership'-paradigm</strong> that is so central
in the NCD discourse. NGOs, CSOs, industry and academia have been joined
together under the umbrella term 'stakeholders' and have been invited to join
the global debate, without any clarity on their different roles or safeguards
against conflict of interest [23-26]. The Action Plan explicitly calls for the
involvement of the private sector as one of the international 'partners'.
Industry is seen as part of the solution and has declared its commitment to
playing a full part in Civil Society's response to NCDs at the Moscow
Conference [27]. <strong>We strongly believe that this proposed
'partnership'-approach is entirely the wrong strategy.</strong> There are
numerous examples of the powerful sway that the tobacco, alcohol, and food
industries have over international governments and how this impedes effective
health policy [23]. Evidence suggests that these corporate social
responsibility strategies are intended to facilitate access to government,
co-opt nongovernmental organizations to corporate agendas, build trust among
the public and political elite and promote untested, voluntary solutions over
binding regulation [26]. While the tobacco industry is not allowed at the
negotiation table because of an "intrinsic conflict of interest", the
Global Alcohol Producers Group (GAP-G) was a civil-society representative at
the UN HLM. Predictably, given existing evidence on efforts by the alcohol
industry to prevent effective public health policies, they pushed for voluntary
rather than regulatory approaches [26]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The political declaration contains no references to international
legislation surrounding the marketing and taxation of alcohol, but instead
urges measures favoured by industry such as partnership working, community
actions, and health promotion [23]. These kind of soft actions had been
previously promoted by the World Economic Forum - also sitting at the table at
the HLM - stating that "the food and beverage industries have a crucial
role to play in selling healthier alternatives", using the example of
PepsiCo's announcement to stop selling high-sugar drinks in primary and
secondary schools worldwide; and that "contemporary marketing and behavior
influencing methods are undervalued in public health and should be fully
incorporated into prevention programmes"[28]. It is noteworthy that
evidence suggests that educational interventions are the least effective means
of reducing alcohol-related harm, and that alcohol industry-funded educational
programmes are ineffective and potentially counter-productive, like their
counterparts funded by the tobacco industry [26]. Another interesting fact is
that PepsiCo promptly decided to spend 30% more on advertising when the CEO was
facing doubts from investors and industry insiders, who were concerned that her
push into healthier brands had distracted the company from some core products
[29]. Nevertheless, PepsiCo had secured the prime side-event slot at the UN
meeting: a breakfast event from 8-10 am on the morning of the summit [23]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">Other 'civil-society representatives' with a clear business interest invited
at the HLM were the International Federation of Pharmaceutical Manufacturers
and Associations (IFPMA), and the International Food and Beverage Alliance
(IFBA) [29]. A senior director of the WEF was also part of the Civil Society
Task Force set up by the President of the General Assembly. In addition,
GlaxoSmithKline, Sanofi-Aventis, and the Global Alcohol Consumers Group were
included within the official US delegation and drinks companies Diageo and
SABMiller were coming from the UK [23]. The representatives of the food and
beverage industry succeeded in deleting a specific target of reducing
population salt intake to less than 5g per person per day from the draft
political resolution [23]. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>Instead of establishing partnerships with industry, the UN and WHO
need to put up firewalls between their policy making processes and the alcohol
and food companies whose products stoke chronic disease and the drug and
medical technology companies whose fortunes rise with every diagnosed case.</strong>
In a Lancet article on conflict of interest at the UN HLM Lincoln et al have
urged for the adoption of the following recommendations in the political
declaration and follow-up actions to the high-level meeting on NCDs [30]: <span></span></p>
<ul style="margin-bottom:0in" type="disc"><li class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:"Times New Roman"">WHO should develop a code of
conduct that sets out a clear ethical framework to identify and address
conflicts of interest, eliminating those that are insurmountable and
managing those regarded as acceptable after a thorough risk/benefit
analysis. Article 5.3 of the WHO Framework Convention on Tobacco Control
provides an example of a framework that safeguards public health policy
from the influence of the tobacco industry.<span></span></li><li class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:"Times New Roman"">This code of conduct and
ethical framework should be used to guide any interactions with the
private sector in NCD prevention and control at UN, regional, or national
level and to differentiate clearly between no involvement in policy
development and appropriate involvement in implementation that complies
with existing regulations and the principles established in the code of
conduct.<span></span></li><li class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:"Times New Roman"">This code of conduct should
be mandated at the international UN level, and adopted as good practice
recommendation for action by member states.<span></span></li></ul>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">The authors emphasized that, without such safeguards, policies and
recommendations will invariably be weakened to suit the interests of powerful
corporations, and this is exactly what happened. The Political Declaration does
not go any further than recognizing "the fundamental conflict of interest
between the tobacco industry and public health" [19]. Health was again
undermined by prioritising the interests of the food and beverage industries,
as well as the pharmaceutical, technology, and treatment companies, over the
public good.<span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>Because of industry influence, the political declaration coming out
of the UN HLM lacks clear and measurable targets and relies only on voluntary
action</strong>. Instead of the promised 'action-oriented outcome document' in
General Assembly resolution 65/238, there are only vague intentions "to
consider" and "work towards". This is one of the main
shortcomings of the political declaration since NGOs, CSOs and academia had
repeatedly stressed the urgent need to create of a small set of global goals,
targets and indicators for NCDs [31]. The lessons from HIV indicate that
measureable targets create accountability and spur action. Despite these
messages from civil society, the proposed overarching goal to cut preventable
deaths from NCDs by 25% by 2025 was not included because of opposition from the
US, Canada and the EU [32]. Instead, industry has succeeded in its call for
voluntary measures:<strong> the declaration calls upon WHO to prepare
recommendations for a set of voluntary global targets for the prevention and
control of NCDs, before the end of 2012</strong> [19]. National leaders have
embraced lame vendor-friendly voluntary solutions instead of effective
regulations governing advertising, product reformulation, package labelling,
government procurement, and VAT reforms [23]. The document is infused with
elusive and vague terms: "may" instead of "will" and
"encourage where appropriate" instead of "provide". This
clearly is a great failure of the High-Level Meeting. If voluntary measures are
put in place, who's going to monitor and who's really going to hold the various
players, governments, industry and civil society, to account? <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">This voluntariness is also reflected in the<strong> lack of clear
commitments to increased financing</strong> for NCD action. Member States at
the HLM called for the fulfillment of all official development assistance-related
commitments and declared to promote all possible means to identify and mobilize
adequate, predictable and sustained financial resources, and to consider
support for voluntary, cost-effective, innovative approaches for a long term
financing of non-communicable disease prevention and control. This falls short
of requests by civil society to include: (1) taxation on tobacco and a levy on
currency transactions, (2) the integration of NCDs in overseas development
assistance programmes, and (3) the inclusion of NCDs in existing global funds
and initiatives [31]. We are concerned that, without clear commitments and
mechanisms to increase funding for NCDs, donors will shift resources from
communicable programs to non-communicable programs instead of adding them to
the existing envelopes. The double burden faced by countries should be
recognized. As pointed out by Julio Frenk at the Moscow Conference, global
health is not a zero<span style="font-family:"MS Mincho"" lang="JA">‐</span>sum game [27]. As
for the Solidarity Tobacco Levy (STL) proposed by the Task Force for Innovative
Financing for Health Systems and backed up by Bill Gates, we caution that the
goal of taxation should be to reduce consumption only,as raised by the Indian
delegation at the Moscow Conference [27]. The STL would in a way send a message
of legitimizing tobacco. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>Next steps</strong><span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">In the final paragraphs of the HLM political declaration, Heads of State
call upon WHO to build on continuing efforts to develop before the end of 2012,
a <strong>comprehensive global monitoring framework</strong>, including a set
of indicators, capable of application across regional and country settings,
including through multisectoral approaches, to monitor trends and to assess
progress made in the implementation of national strategies and plans on
non-communicable diseases. They further request the SG, in close collaboration
with WHO and Member States, to submit to the General Assembly, at its
sixty-seventh session, <strong>options for strengthening and facilitating
multisectoral action</strong> for the prevention and control of
non-communicable diseases<em> through effective partnership</em> and to present
to the General Assembly at the sixty-eighth session a <strong>report on the
progress</strong> achieved in realizing the commitments made in the
declaration, including on the progress of multisectoral action, and the impact
on the achievement of the internationally agreed development goals, including
the Millennium Development Goals, in preparation for a comprehensive review and
assessment in 2014 of the progress achieved in the prevention and control of
non-communicable diseases. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">We urge for the development of a framework to guide countries in adopting a
Health in All Policies-approach, addressing the social determinants of health
and looking for synergies with other global health and development challenges.
We encourage the involvement of <em>public-interest</em> civil society
organizations but do not support the push for public-private partnerships. We
urge WHO to develop a code of conduct that sets out a clear ethical framework
to identify and address conflicts of interest, eliminating those that are
insurmountable and managing those regarded as acceptable after a thorough
risk/benefit analysis to be used to guide any interactions with the private
sector in NCD prevention and control at UN, regional, or national level. This
code of conduct should be mandated at the international UN level [30]. Finally,
we urge for a replacement of the voluntary targets by clear goals to ensure
accountability. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">As argued by Rasanathan and Krech in their excellent article on the social
determinants of health and NCDs, commitment towards a global agenda for non-communicable
diseases is only a partial solution. As the 2015 deadline draws near,
coordinated global action, keeping equity foremost, is needed on the unfinished
Millennium Development Goals agenda, climate change, social protection and non-communicable
diseases. This requires a social determinants approach at global level, with
aligned strategies, implementation and monitoring. [5] <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman""><strong>Notes </strong><span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">(1) The Global Strategy puts forward three goals, the second of which is to
"reducde the level of exposure and populations to the common risk factors
for non-communicable diseases (...) and their determinants". The 3th
objective of the Action Plan, which is the translation of the 2nd goal of the
Global Strategy, however, does not make any reference to the underlying
determinants of what is called an unhealthy lifestyle. In addition, actions on
the social determinants of health are not included in the range of actions
proposed for Member States under Objective 3 in the Action Plan. It is striking
that the socioeconomic determinants of NCDs get so much attention throughout
the document but are left out under the objective where specific action to
address them could be proposed. We are left with the promotion of more
attention towards the determinants, and more research and monitoring. <span></span></p>
<p style="margin-right:0in;margin-left:0in;font-size:12pt;font-family:"Times New Roman"">(2) To illustrate this, it is interesting to look at what became of the
following activity planned by the Secretariat in the 2008-2013Action Plan under
objective 1: "draw up a document in support of policy coherence, pointing
out connections between the findings of the Commission on Social Determinants
of Health and the prevention and control of non-communicable diseases; and take
forward the work on social determinants of health as it relates to non-communicable
diseases". In the report that will be presented now at the 130th EB in
January, the following activity is the implementation of what the Secretariat
had promised to do: "the evidence linking non-communicable diseases with
socioeconomic development, poverty and the health-related Millennium
Development Goals was reviewed. A summary of the findings was included in WHO's
Global status report on non-communicable diseases 2010".<br>
Note that while the initial idea was to depart from the social determinants of
health and look at their implication for prevention and control of NCDs, it
became narrowed down to how NCDs link to socioeconomic development, poverty and
the MDGs. Moreover, no separate document in support of policy coherence was prepared.
Instead the findings got scattered out in a 176 page document (the Global
Status Report), which will most likely not reach policy makers from different
government departments and thus remain dead letter.<span></span></p>
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