By Hayley MacGregor, STEPS Centre member
The UN High-level Summit on Non-communicable Diseases now underway comes at an important moment for the development community. With just over 50 per cent of the world now living in cities, and with the percentage of the global population over 60 years of age expected to double by 2050, we must recognise and internalise that the demographics of the world are changing.
We must think through the implications of urbanisation, not only for health, but also for development and governance approaches more generally.
Societies and systems from the US to Uganda are groaning under the pressures of demographic shifts. Focusing attention on non-communicable diseases (NCDs) at such a high-level forum is one good step in this direction.
The only other time that the UN has focused on disease in this way was in 2001, when concern regarding the effects of the HIV epidemic led to the formation of the Global Fund to fight the 'big three', AIDS, turberculosis and malaria. The discourse today resonates strongly with that time: the urgency of the issue is being conveyed through the language of pandemics, a global crisis and dire consequences if a coordinated response is not forthcoming.
The challenge of non-communicable diseases
The quoted figures are indeed alarming. In particular, it is the growing 'double burden' of communicable and non-communicable diseases in low- and middle-income countries that has crept up on us – a burden that is predicted to increase. 29 per cent of deaths from NCDs are in people under 60 years of age, which has significant economic and social costs.
Diabetes, cardiovascular disease and cancer, long associated with rich Northern populations, are inflicting a heavy toll of suffering and disability around the globe.
There are the conditions included in the NCD category that have had less time in the limelight, such as: mental disorders; chronic lung conditions associated with smoking; and environmental health effects linked to industrial pollution. Several disease lobby groups are crying neglect and articulating their agendas.
Preventing non-communicable diseases 'upstream'
But a politics of disease hierarchies is not the point. It is the fact that these conditions are considered to be to some degree preventable. They tend to run a chronic, progressive course if not detected early and managed carefully. In this respect, the regimen is classically a combination of long term drug treatment and risk reduction, mostly prescriptions for lifestyle change.
A medicalised view focussing on individual behaviour change modification, or even a health systems approach, is too limited a focus. Key figures in the medical establishment have pointed out the importance of structural factors that need to be addressed in the name of 'upstream' prevention: the regulation of the food, tobacco and alcohol industries has been mentioned repeatedly.
In this respect prevention is no easy challenge and will require considerable political will to take on powerful global players.
The interests of the big drug companies also require greater scrutiny: do they not stand to gain from an increased profile and a 'pharmaceuticalisation' of the problem? And who among them will be the winners and losers as these 'Northern' medical problems go global?
Chinese and Indian firms are on the brink of being able to manufacture generic biotech medicines used to treat various NCDs. In the early 2000s, after a protracted patent battle, generic HIV/AIDS medicines were made available in developing countries. Will drugs for NCDs follow a similar path?
Lessons from development for addressing non-communicable diseases
This is one area where a development perspective could add to the understanding of NCDs: there are lessons to be learned from the HIV experience.
But development perspectives also tell us that it is vital that the experiences and viewpoints of people living in the global South are taken into account in the debates, because policy responses and invested resources are going to require difficult negotiations and trade-offs.
Will the poorer sectors of the rapidly growing urban populations prepare food at home or eat from street vendors in the years to come? How will regulation of the food industry relate to the informal food sector? What will tobacco controls mean for the livelihoods of small-scale farmers? As the world's population ages, who will fill the gaps in the formal and informal care sectors?
The link between chronic illness and poverty is well established. One study for POVILL found that in two rural areas in China, the costs of long-term outpatient treatment of chronic diseases like diabetes were equivalent to one-off inpatient care that did not require surgery. While the costs were similar, inpatient costs were covered by the state-run medical insurance, while outpatient costs were not.
The current millennium development goals (MDGs) do not include targets for NCDs. As we look beyond the MDGs, it is timely to consider what research in governance, social protection, changing livelihoods, patient participation in health care, and health and urbanisation can add to the current debates and future policy processes.
This article was also published on the Institute of Development Studies website
Tuesday, 20 September 2011
By Hayley MacGregor, STEPS Centre member