This chart lists a few of the many ways in which unhealthy lifestyles and chronic diseases it linked to progress towards achievement of each of the eight Millennium Development Goals.

However, this is only the start of the list: this is a ‘wiki’ chart, and we would very much appreciate your suggestions for other ways in which NCDs are linked to, or could impede, development.

Goal 1: Eradicate extreme poverty and hunger

• Household income may be reduced if those of working age are required to care for sick relatives.
• The cost of health care, particularly for long-term illnesses, drives many already poor families into extreme poverty.
• Spending on tobacco displaces spending on essentials such as food – in Bangladesh, a pack of 20 cigarettes is twice the cost of a 1kg bag of rice.

Goal 2: Achieve universal primary education

• Children may be taken out of school to provide long-term care for relatives suffering from chronic diseases.
• Spending on tobacco displaces families’ spending on education.

Goal 3: Promote gender equality and empower women

• Girls are most likely to be required to provide long-term care for relatives suffering from chronic diseases, damaging their chances of completing their education.
• CVD, in particular, is often seen – wrongly – as a disease that affects primarily men, and development has taken relatively little account of its impacts upon women, both direct (it is a major cause of death among women) and indirect (e.g. caring for family members with CVD).
• Raising awareness of the dangers of smoking to women (including when pregnant) may help to stem the increase in smoking among women and girls in many cultures.

Goal 4: Reduce child mortality

• Smoking while pregnant affects the health of the baby, and children are also most at risk from the effects of passive smoking, leading to respiratory disease.
• Poor maternal nutrition is a major cause of child mortality.

Goal 5: Improve maternal health

• Gestational diabetes has more than just immediate health problems – women who have had it are more likely to develop type 2 diabetes later in life, and if it is not managed then their babies are more at risk from some health problems.
• Good nutrition (including fresh produce) and taking exercise when pregnant will have short-term and long-term benefits for mother and baby.

Goal 6: Combat HIV/AIDS, malaria and other diseases

• Tackling poor diet, smoking and physical inactivity will help to reduce the prevalence of many chronic diseases.
• Tackling smoking and improving diet also have benefits for those with diseases already mentioned in the Goal, such as TB and HIV/AIDS.

Goal 7: Ensure environmental sustainability

• Growing and transporting local fresh produce benefits diet and long-term health, and can have a lower carbon footprint.
• Sustainable cities require that the environment is conducive to health – such as lowering air pollution by providing good alternatives (walking, cycling) to motor transport, or working to reduce the amount of rubbish (particularly harmful littering).

Goal 8: Develop a global partnership for development

• NCD is a global issue, and lessons can be learnt from developed countries that could help to slow the epidemic in developing countries. Without a ‘joined-up’ approach, obesity and tobacco use will not be eradicated.
• Working with pharmaceutical companies and others to ensure access to essential NCD drugs.

The effect of NCD on the Goal

‘The omission of NCDs from the MDGs is crucially significant because the MDGs form the framework and goals for investment in international development’
Dr Fiona Adshead, Director of Chronic Diseases and Health Promotion

The Millennium Development Goals (MDGs) have been very successful in driving development efforts,ⁱ and their aims have become firmly established in the strategies and funding of aid agencies, the UN and governments. However, in the 10 years since the MDGs were drawn up, it has become evident that the burden of chronic non-communicable diseases (NCDs) has been rapidly rising in low- and middle-income countries – perhaps partly because the speed and depth of the transition was not fully anticipated in 2000, NCDs were not specifically mentioned in the MDGs.

With the MDGs as currently constituted due to come to an end in just five years’ time, in 2015, there is a clear need to reach a consensus: what is the most appropriate way to react to the changing disease profile of the developing world, particularly regarding the MDGs, so as best to catalyse action and investment on health and development?

This document is part of this process. Its aim is to provoke discussion – it does not seek to provide answers. It briefly introduces the MDGs and NCDs, explains the importance for development of tackling NCDs, lists some possible ways of moving NCDs up the development agenda, and provides a list of references and useful sources.

It will be posted on the 3FOUR50 website, where comment will be solicited from a wide range of interested parties. While we expect much of the comment to come from health professionals, NCD NGOs and development professionals, the views of those living with the effects of chronic diseases and poverty in developing countries would be particularly welcome.

For further information and some further background documentation, please visit www.3FOUR50.com or contact Katy Cooper at C3 Collaborating for Health (katy.cooper@c3health.org).

Comment or read other coments on Introduction

2. The MDGs and NCD

2.1 The MDGs

The Millennium Development Goals were presented to the UN General Assembly in 2001, growing out of the Millennium Declaration (2000) and an earlier set of similar Goals set by the OECD (Organisation for Economic Cooperation and Development). There are eight Goals, under each of which fall a number of targets, and indicators by which progress can be measured at individual country level. The Millennium Declaration also called for the glaring inequalities in wealth and opportunity to begin to be evened out, but this was not incorporated in the MDGs.

The MDGs reflect a shift from earlier prioritisation of economic growth to a more holistic approach to development that includes poverty eradication and human wellbeing.ⁱⁱ

The Goals have been very successful in driving development, and have become so firmly grounded that they are considered to be an ‘ethical imperative’.ⁱⁱⁱ

Health is clearly mentioned in three of the eight Goals (4, 5 and 6), which is a recognition of the influence of health on poverty.

The MDGs

For a list of some ways in which NCD impacts upon each Goal, see [link] – and input to that list is welcome.

Comment or read other coments on Section 2.1

2.2 Chronic non-communicable diseases

Chronic non-communicable diseases are here defined as the four major NCDs^iv: cardiovascular disease, type 2 diabetes, cancers and chronic lung disease. Between them, these diseases account for 59% of the 57 million deaths annually and 46% of the global burden of disease – double the number of deaths from all infectious diseases (including HIV/AIDS, TB and malaria), maternal and perinatal conditions, and nutritional deficiencies combined.^v The majority – up to 80 percent – of premature deaths from these diseases could be prevented by tackling just three risk factors: poor diet, tobacco use and lack of physical activity.

NCDs are not necessarily ‘diseases of affluence’ – they are largely due to lifestyle changes that are, in many cases, inherent to economic development and often particularly affect the socioeconomically disadvantaged. An example of this is the ongoing and unprecedented levels of urbanisation – over half the world’s population now live in cities, and the urban population is growing by over a million people a week.^vi In cities the availability of fresh food and healthy physical activity may be severely constrained, and unhealthy habits such as smoking can predominate. Where access to essential medicines (such as insulin) is limited, chronic disease is even more likely to cause years of disability and early death.

Comment or read other coments on Section 2.2

2.3 A crucial omission

‘Over the last few years, clarion calls have been made to major international health agencies and global initiatives like the Millennium Development Goals to broaden their objectives to include CVD – especially hypertension – as an urgent investment in low-income and developing countries.’
Dr Kingsley Akinroye, President, African Heart Network

The health-related MDGs were intended to ‘serve as markers for the most basic challenges ahead’,^vii between 2000 and 2015, and were to be achieved from a baseline taken in 1990. However, between 1990 and the present day, the majority disease burden of many low- and middle-income countries has dramatically shifted from infectious diseases to NCDs. Between 2005 and 2015, in Africa it is estimated that deaths from NCDs will rise by 27 per cent, and in SE Asia infectious disease deaths will fall by 10 per cent and NCD deaths rise by 25 per cent.^viii

Figure 1, below, shows a particularly striking demonstration of the change in cause of death during this period in Matlab, a rural area in Bangladesh.

Unfortunately, while HIV/AIDS, TB and malaria are mentioned by name in the MDGs (with three targets and 10 indicators), the major chronic diseases are not specifically mentioned, and are consequently often sidelined. The impact of the diseases on economies, health systems and families can be devastating – see Box.

Box: Some key statistics
-Cardiovascular disease killed 17.1 million people in 2004 – 29% of all global deaths. 82% of deaths from CVD take place in low- and middle-income countries.^ix
-An example of CVD’s impact on those of working age: in 1990, CVD-related mortality among 30–39-year-olds was 47.4 cases per 100,000 of the Kyrgyzstan population, whereas in 2004 it increased to 56.7 cases per 100,000. In comparison, this rate for Sweden was 11 cases per 100,000.^xxi -10–20 million people in Sub-Saharan Africa may have hypertension – and its cost-effective treatment could prevent 250,000 deaths a year.-The latest WHO estimate (in 2000) for the number of people with diabetes worldwide is 171 million. This is likely to increase to at least 366 million by 2030.^xii-In 2008, over 12 million new cases of cancer were diagnosed worldwide. By 2030, it is estimated that there will be over 26 million incident cases of cancer annually.^xiii-In 2010, tobacco will kill 6 million people, 72% of whom live in low- and middle-income countries.^xiv-Physical inactivity is estimated to cause 1.9 million deaths globally each year.^xv-Projected foregone national income due to NCDs, between 2005 and 2015, is estimated to be $236.6 billion in India.^xvi-Smoking also imposes huge economic costs – in India, for example, the direct costs of smoking are estimated to be US$7.2 billion per year.^xvii
-In 2005, the cost of achieving the MDGs in all countries was estimated by the UN Millennium Project to be in ‘the order of $121 billion in 2006, rising to $189 billion in 2015’.^xviii

This neglect of NCDs from the MDGs is argued to have skewed the development agenda away from the prevention, management and treatment of NCDs, even though this could have a major impact on economic growth. NCDs are not as visible, or as self-evidently problematic, as images of child malnourishment or infectious disease.

‘Incomprehensibly, the Millennium Development Goals do not include explicit targets for the non-communicable diseases, but it is hard to see how the goals can be achieved without addressing NCDs, especially for the goals related to health outcomes, poverty and hunger’
Professor Judith Mackay, World Lung Foundation

However, it is a painful truth that, as progress is made on tackling the most abject poverty and infectious disease, the major risk factors begin to take root – and, after a few years, NCDs begin to undermine the development progress made to date. Better NCD prevention, management and treatment is also contingent on improving health systems – improvement that may, particularly in low-income countries, be out of reach. Good adult health is essential for economic development, and it is doubtful whether the MDGs could ever be achieved in their entirety without tackling this new burden of NCDs, when the economic, social and emotional consequences of the new epidemic are so great, and growing.

Comment or read other coments on Section 2.3

2.4 The seeds of change?

‘The 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, unanimously adopted by WHO Member States at the World Health Assembly, clearly calls for the inclusion of NCDs in global discussions on development’
Janet Voûte, WHO Partnerships Adviser

There are increasing signs that NCDs are being taken seriously as a global problem:

-The World Health Organization has recently published an Action Plan for the achievement of its Global Strategy for the Prevention and Control of Noncommunicable Diseases.

-Non-governmental organisations for the major chronic diseases are increasingly calling for NCDs to be more prominent in the development agenda, such as the publication of a call to action from the World Heart Federation, UICC and International Diabetes Federation in 2009.^xix

-The impact of smoking on health and development is becoming a priority for some aid funders, most notably the Bloomberg Foundation and Gates Foundation, which in 2008 committed $250 million and $125 million respectively to tobacco control in developing countries.

-In July 2009, a Ministerial Declaration from ECOSOC (the UN’s Economic and Social Council) on ‘Implementing the internationally agreed goals and commitments in regard to global public health’ explicitly included non-communicable diseases as representing ‘a leading threat to human health and development’.^xx

-The Heads of Government of the Commonwealth of Nations^xxi (an intergovernmental organisation of 54 independent member states, all but two of which were formerly part of the British Empire, representing one-third of the World’s population) recently issued a statement affirming their commitment to countering NCDs, and calling for indicators and targets to be included within the MDGs.

-The World Economic Forum has estimated the epidemic of NCD to be one of the most important ‘global risks’ in terms of likelihood and severity^xxii (see Figure 2 – chronic disease is indicated by the number 31, circled), and is now setting up a new forum to discuss NCDs.

-Locally, too, strategies to tackle NCDs are being developed – for example, the Caribbean Community (CARICOM) agreed the Port-of-Spain Declaration: Uniting to Stop the Epidemic of Chronic NCDs in 2007, and, building on this, is in the final stages of developing a three-year strategic plan, Non-Communicable Disease Prevention and Control: 2009-2013.^xxiii

Comment or read other coments on Section 2.4

2.5 The time to act

By reducing death rates from NCDs by 2 per cent a year over and above existing trends, the WHO estimated that between 2005 and 2015 (when the MDGs expire) a total of 36 million premature deaths could be prevented, most of which would be in low- and middle-income countries.^xxiv However, the burden of NCDs is in many areas continuing to rise, and will continue to grow post-2015, particularly as demographics change. Many developing countries (for example, in North Africa) have a large proportion of young people, who will begin to suffer from NCDs in middle age– with adverse consequences for economic development – unless the risk factors are addressed as soon as possible.

There is currently an important window of opportunity to tackle NCDs:

Although not all development agencies will heed the message, and not all countries will be able to deliver the changes that we call for, this pragmatism should be balanced with aspiration: there is much that could be done, even in relatively resource-constrained settings.

Comment or read other coments on Section 2.5

3. The options for change

There are several ways in which NCDs could be integrated further into the development agenda, and some suggestions are below. They are not exhaustive, nor mutually exclusive, and are intended only to provoke discussion. Finding a consensus position on ways forward will greatly assist progress, as the voice of those advocating for change will be greatly enhanced by using a consistent message, with clear stated aims.

Please go online [link] to leave your comments and suggestions. We particularly welcome comments from those who are directly affected by NCDs in developing countries.

3.1 Bringing NCD into the MDGs

There are several ways in which NCDs – their prevention and treatment – could be highlighted within the MDG system:

1. mainstreaming the diseases and risk factors throughout the existing MDGs;
2. modifying the existing Goal on health;
3. creating a separate layer of new, locally defined targets relevant to NCDs, as an ‘MDG Plus’;
4. creating a completely new Goal, to reflect the perceived importance of NCDs in poverty eradication and development.

Reaching a consensus on how NCDs could be most effectively incorporated should be a priority, as any extended or re-orientated MDGs post-2015 will need to acknowledge the role of adult health and NCDs in economic development.

We welcome your thoughts on all these suggestions – and any others – including on the timing for advocacy efforts: is now the right time to be lobbying for change?^xxv

a) Mainstreaming

Mainstreaming NCDs involves weaving NCDs throughout the MDGs, by mentioning specific diseases and drug treatments, and by incorporating relevant indicators. Mainstreaming enforces the fact that NCDs impact upon many of the existing Goals and that, by adding and achieving new indicators/targets, these Goals are more likely to be achieved. This approach has been supported by the Commonwealth Heads of Government, who recently called for ‘indicators to monitor the magnitude, trend and socio-economic impact of NCDs [to be integrated] into the core MDG monitoring and evaluation system’.

Some suggestions could include:

Goal 4 (child health):
e.g. a new indicator on child BMI: this would not only identify where children are under-nourished, but also highlight where there are issues with childhood obesity, which is a strong determinant for adult obesity and ill-health.

Goal 5 (maternal health):
e.g. a new indicator on gestational diabetes.

Goal 6 (diseases):
e.g. a new indicator on the proportion of smokers in the population: smoking kills a quarter of smokers in their most productive years of employment, with devastating social and economic effects.^xxvi In the Philippines, for example, the poorest households in 2003 spent more on tobacco than on health, education and clothes.^xxvii In addition, other risk factors (alcohol and salt intake, hypertension) and diseases (such as diabetes prevalence and CVD rates) could be incorporated as indicators and targets into this Goal.

Goal 8 (partnership):
Mention of access to essential medicines^xxviii is already in this Goal, and drugs relevant to the treatment and prevention of NCDs (such as statins and insulin) could be highlighted. Aid has largely focused on drugs to treat the diseases mentioned specifically in the MDGs (notably HIV, malaria and TB), and a recent report by the MDG Gap Task Force has called particularly for ‘greater priority to treating chronic diseases in health-care policies in developing countries and in global health partnerships’.^xxix

Comment or read other coments on Section 3.1(a)
Discussion:
What are the priorities for new indicators/targets, were we to advocate for their incorporation within the existing MDG framework?Would mainstreaming in this way provide enough impetus for the development agencies to begin to take greater note of the impact of NCDs?Should the targets be gender-specific (for example, distinguishing proportion of male and female smokers in a population; death rates from CVD by gender, etc.)?

b) Modifying the existing Goals on health

Currently, Goal 6 on health is to ‘Combat HIV/AIDS, malaria and other diseases’. Given the increasing burden of NCDs, the Goal could be reworded, perhaps as: ‘Combat infectious diseases such as HIV/AIDS and malaria, along with non-communicable diseases such as cardiovascular disease, diabetes, cancer and chronic lung disease’.^xxx

Comment or read other coments on Section 3.1(b)
Discussion:
Is rewording the MDGs a practical aim, or would it merely confuse?
What rewording would be most appropriate?

c) Setting local targets

All countries face different development challenges – indeed, many developing countries have already achieved or exceeded some of the targets set by the MDGs. The targets are, of course, a minimum standard – achieving a target should not lead to complacency – but there may, at this point, be even more reason to begin to address NCDs, as their impact will be increasingly felt over the next decades.

‘By itself, chronic disease may not have made the MDGs, but through our programme of work, we have placed it firmly within the targets.’
Dr Tracey Koehlmoos, icddr,b (Bangladesh)

ome countries have already adapted the MDG framework to provide impetus for further improvement on NCDs, for example:

- Following a consultative process with NGOs, Thailand has set new, ‘MDG-Plus’ targets and indicators (including the prevalence and death rate from heart disease), and with a focus on inequity (as noted above, the Millennium Declaration had called for inequality to be tackled, but it did not form part of the MDGs). This new structure is now providing the framework for UN development work in the country.^xxxi

- Mauritius has set a new target to halt and begin to reverse (by 2015) the incidence of NCDs.^xxxii

Comment or read other coments on Section 3.1(c)
Discussion:
What would be a list of the priorities for local targets/indicators, which could provide a starting point for countries hoping to follow Thailand’s lead in developing a local ‘MDG-Plus’?
Are local targets more pragmatic/useful than advocating for new indicators/targets to be added to the MDGs?

d) Creating a new Goal

The final, and most radical, suggestion is to advocate for an entirely new MDG, in the hope that this will catalyse much greater development aid on NCDs. Such an MDG could be disease specific (e.g. following the structure of Goal 6), or focused specifically on prevention. The latter would have many synergies with other Goals, as, for example, smoking cessation would positively influence Goal 1 (poverty), Goal 4 (child health), Goal 5 (maternal health) and Goal 6 (notably through its impact on TB).

Comment or read other coments on Section 3.1(d)
Discussion
Is calling for a new MDG feasible or even sensible – would a new MDG (whether in 2015 or before) serve to help development funders focus their efforts, or would it be detrimental?

3.2 Other suggestions

There are many other suggestions for increasing awareness and action on NCDs, including the following – and once again we welcome your comments.

a) Integrating pilot projects on NCD into existing development programmes

Particularly in a time of recession, combining NCD treatment and prevention with existing programmes could be a way to achieve synergies while minimising extra investment.

This could include working with environmental sustainability programmes on introducing non-polluting stoves and healthy transport systems, or integrating long-term management of chronic diseases with diseases such as HIV and TB, which are often now chronic in nature.

Comment or read other coments on Section 3.2(a)
Discussion:
Where are the clear points of overlap between NCD treatment/prevention and existing development programmes?
What organisations could be interested in bringing NCDs into their programmes?

b) A UN Special Session on NCDs

A UN Special Session on NCDs would be a discussion at the General Assembly of the UN, covering many aspects of non-communicable diseases. A three-day Special Session on HIV/AIDS^xxxiii was held in June 2001, which led to a Declaration of Commitment, the first global ‘battle plan’ against the disease.

The UN Economic and Social Council, ECOSOC, is the body responsible for deciding what topics receive a Special Session at the General Assembly. NGOs (WHF, UICC and IDF) released a ‘call to action’ at the ECOSOC meeting in 2009,^xxxiv to raise awareness within ECOSOC, and in the hope that a Special Session would be called. Governments and bodies such as the EU can also put pressure on ECOSOC to call for a Special Session.

Most recently, the Commonwealth Heads of Government statement of November 2009 called for: ‘a Summit on NCDs to be held in September 2011, under the auspices of the United Nations General Assembly, in order to develop strategic responses to [NCDs] and their repercussions’.^xxxv

Comment or read other coments on Section 3.2(b)
Discussion:
Most importantly: what would a Special Session hope to achieve?
What would be priorities for discussion at a Special Session? For example, it could discuss changes to the MDGs, or how to integrate pilot projects on NCD into existing programmes.

c) Global Fund for NCD

Although not focusing on NCDs, in the Lancet^xxxvi recently, Banerjee et al. called for a global ‘Health Impact Fund’, a global agency that would provide rewards based on registered drugs’ contributions to global health (membership would be optional). This proposal is not disease- or country-specific, and would require governments to make commitments to support the fund – set, in this case, at 0.03 per cent of gross national income. A similar approach for a Global Fund to tackle NCDs has also been discussed in the past – however, resources in the current recession are even more constrained.

Comment or read other coments on Section 3.1(c)
Discussion:
Would calling for a Global Fund for NCDs be practical or timely?

4. Next steps

This document – and the discussion for which it calls – aims to canvass opinion, with the hope of developing a consensus on the most fruitful ways in which to bring NCDs into the development agenda. Over the next five years there will be much discussion about how the MDGs might be reconstituted to make them future-proof, sustainable and effective after 2015, and if the case is to be made for the inclusion of NCDs, we will require consistent messages, delivered at key points and by key people and organisations.

The next steps are:
-Gathering together of comments on this document, and production of a précis of responses
-A proposed meeting, to be held in spring 2010, of some of the key contributors to the discussion, with a view to producing a consensus document.
-Using the documentation to advocate at the UN, in particular at ECOSOC and its commissions (such as the Commission on Population and Development), and at the General Assembly high-level plenary meeting on the MDGs in September 2010. This meeting is ‘an event of decisive importance’ that will ‘reinforce the global partnership for development and support strategies to prevent backsliding and accelerate progress towards the achievement of the MDGs and other internationally agreed development goals’.^xxxvii
- Developing awareness in the media, through placement of editorials in national newspapers during major health-related conferences.

Comment or read other coments on Section 4

5 ‘The rise of NCDs in developing countries presents an ominous warning and a golden opportunity. A new development scheme – MDGs or something else – should encourage countries to create and follow the path to healthier economic development.’ Rachel Nugent, Deputy Director for Global Health, Center for Global Development

Comment or read other coments on Section 5

Conclusion

The evidence indicates that tackling NCDs is as essential to economic and human development as climate change, equality, energy poverty, human rights, and other issues that will be competing for space in the MDGs in 2015.

By raising the profile of non-communicable diseases, development assistance may begin to flow, and the looming epidemic of NCDs in developing countries should and could – at least in part – be averted.