In September 2011, the United Nations General Assembly passed a Resolution adopting the Political Declaration on the Prevention and Control of non-communicable diseases including cardiovascular disease, cancer, diabetes and chronic respiratory disease (NCDs). The Declaration was indeed a historic landmark in public health for several reasons. First, it was only the second meeting at the world’s highest political level to consider a health problem. The first one 10 years previously was to address the scourge of HIV/AIDS and much of the concern at and impetus for that meeting sprang from the death toll from the disease. The world was gripped by images such as those of the AIDS quilt representing the deaths of hundreds or thousands of those who had died. The Declaration stated unequivocally that “Prevention must be the mainstay of our response”, but there was also an urgency to make more and better therapies available. To a certain degree the resolution on NCDs was similar, because although the specter of unavoidable mortality was not as sharply painted as was the case for AIDS, the dominant idiom was for prevention and control in that order. A central feature was that the possibility of success was enhanced because of the similarity of the risk factors for this group of chronic diseases. These risk factors are tobacco use, the harmful use of alcohol, unhealthy die and physical inactivity.
The other remarkable phenomenon was the unanimity of the response to the call for prevention and control of NCDs. The signatories to the Political Declaration were all the countries of the world-however one might categorize them, as they all saw the gravity of the epidemic and visualized the social problems it had caused and would cause. There was acknowledgement that this was a global problem and its roots and control lay in and in many instances depended on factors that were genuinely international or multinational.
This unanimous commitment made in that Declaration and the subsequent acceptance of the overarching goal of reducing “preventable” mortality by 25% by the year 2025 pose a particularly acute challenge for many of the Lower and Middle Income Countries (LMIC). One often reads of the double burden of the communicable and non-communicable diseases that these countries bear, but the point comes home sharply when one sees the actual data and notes the rapidity of the change. In Pakistan for example the percentage of deaths from communicable diseases was 47 % in 1994 and 12 years later was 19%. The change in the percentage of deaths for NCDs was equally dramatic-from 47% to 73% over the same period. It is even more striking to note that 51.2 % of deaths in women ages 12 to 49 years are due to NCDs.
The required shift in emphasis and capacity in the health systems must be enormous in countries with these kinds of changes. In one sense it is a tribute to the public health systems, broadly conceived, which are in the main responsible for the decline in the communicable diseases. But the strain of adjusting to the continuous care model that must be at the heart of the secondary prevention and treatment of NCDs must be staggering. In the majority of the LMIC there are mixed systems of care, often with high out of pocket expenditure at the point of delivery. It is for this reason that the care of NCDs is often cited as a cause of poverty.
But there is another aspect of the prevention of NCDs that has not attracted sufficient attention. There has been little discussion of the relevance of health governance and the political geography of health to the prevention and control of these diseases which depend in large measure on the control of the common risk factors. This approach is facilitated by the presence of a strong central authority with ability through regulation, taxation and legislation to make the needed population based changes to address the risk factors. This poses a particular problem for federal countries in which much of the authority for such population based interventions lies at the provincial or other peripheral level. Federal countries with dispersed authority will find it difficult for example to reduce the population’s consumption of salt or increase tobacco taxes universally, both of which are cost-effective interventions for reducing cardiovascular disease.
Yet another challenge relates to the increasing insistence on universal health coverage as the unifying platform for improving health in the new development agenda. Much of the emphasis in outlining the approaches needed for universal health coverage is on making promotion, prevention, treatment and rehabilitation services universally available and ensuring needed financial protection. It should be noted that this does not embrace the social or population interventions which are critical for the prevention of NCDs.
The world as a whole has committed itself to the prevention and control of NCDs. There will be no single universally applicable roadmap and it behaves us to examine all the genuinely autochthonous models that are developed to this end and I trust one such will come from Pakistan.