International NCD Conference in Copenhagen N-O-N-C-O-M-M-U-N-I-C-A-B-L-E D-I-S-E-A-S-E-S. It is hard enough to pronounce the name; communicating about it is equally challenging. Officially abbreviated NCDs, the diseases hidden behind the acronym include cancer, diabetes, cardiovascular and chronic obstructive respiratory diseases. "We need to realise is that NCDs pose enough of a threat to the future development and security of the world that they warrant a large and commensurate response." Dr Ala Alwan, Assistant General Director at WHO for NCDs (photo: Jesper Westley).   In an effort to underline the development concerns posed by NCDs in developing countries, an international conference was organised by the World Diabetes Foundation and the Danish Ministry of Foreign Affairs in Copenhagen, 15 - 16 April (1). 140 leading public health and development assistance professionals and high ranking government representatives from North and South gathered at the International Conference on The Emerging Burden of Chronic Diseases and its Impact on Developing Countries. Participants included the Ministers of Health from Mozambique, Uganda and Denmark, the Minister for Development Cooperation, Denmark as well as representatives from WHO, World Bank, Norad, IDF, WHF and IUALTD. They presented and discussed the implications of NCDs in low and middle income countries - and they addressed the consequences of not facing up to the reality of this rising pandemic. This is not a competition As we have often reiterated in this Newsletter, the burden of NCDs in developing countries is greatly disproportionate to the meagre resources and attention paid to the area. In short, more people in developing countries die from NCDs than from communicable diseases such as malaria, tuberculosis and HIV/AIDS. But the problem is that NCDs are not part of the health priorities as they are defined in the Millennium Development Goals (MDGs). Currently, finances for the prevention and treatment of NCDs accounts for less than 1% of official development assistance (ODA) for health. The objective of the Conference was to highlight evidence, experience and facts on NCDs and their impact in developing countries and to stimulate frank discussion and reflection on the issues presented to bridge the reality-perception gap. The conference was intended to further enhance the process of partnership development and create advocacy to urgently and appropriately address NCDs in development policy, programming and financing. "We are not talking about competition with the development agenda or communicable diseases; they can - and should be - mutually reinforcing and complementing each other," said Dr Ala Alwan, Assistant Director General for NCDs at the WHO. "What we need to realise is that NCDs pose enough of a threat to the future development and security of the world that they warrant a large and commensurate response." In his opening address Dr Alwan presented the causes of deaths worldwide - a statistics in which 60% of all deaths are attributable to NCDs (2).   Benefits of economic development to be nullified Senior Public Health Specialist from the World Bank, Dr Michael Engelgau presented numbers from India showing the impoverishing effect on households with members who suffer from NCDs. Using cardiovascular diseases (CVDs), diabetes and cancer as examples, he showed how these conditions increase the risk of catastrophic spending and how men with CVDs had much higher risk of falling into impoverishment than those who did not suffer from CVDs (3). By using these examples from World Bank sponsored studies in India, Engelgau's point was that health care in most low and middle income countries is financed out of pocket, i.e. by the patients themselves; and this puts the people suffering from NCDs living in low and middle income countries at great financial risk and consequently increasing poverty. Reading between the lines the message from his presentation was that the benefits of economic development in lifting people from abject poverty will be nullified if attention was not paid to the rising burden of NCDs I would rather have AIDS! Pinpointing the disproportionate health care spending and priorities, Dr Tembu Osborn, Medical Officer at Kijabe Mission Hospital, Kenya, made a compelling presentation called "Realities on the ground: when people with diabetes wish they had AIDS instead." Dr Tembu compared the care between HIV/AIDS patients and diabetes patients at the Naivasha rural District Hospital; the former receives heavy funding and attention translating into improved quality of care. Whereas the HIV clinic runs Monday through to Friday 8am-5pm, the diabetes clinic is open on Thursdays only, 8am-1pm. While there are 4407 registered positive HIV patients at the hospital's HIV clinic, the diabetes clinic at the same hospital attends a total of 350 diabetes patients. Because of the many resources allocated to HIV treatment and care (including distribution of free wheat flour) compared to people suffering from diabetes who cannot even get access to extremely cheap generic drugs, patients who are diagnosed with diabetes lament that it would have been better if they were diagnosed with HIV. Delinquency or action? Tembu's example illustrates precisely the gap in health funding and the consequences for people on the ground. Similar arguments were made throughout the conference, but the big question remained "Why doesn't anybody do something about it?" Research Fellow at the University of Oxford and author of the paper "Drivers of inequality in millennium development goal progress" (4), Dr David Stuckler phrased the consequences of not responding to the funding gap between non-communicable and communicable diseases very clearly: "We stand today where we were with HIV in the 1980s - we can look at the next two decades and intervene to make a huge impact in human lives. Are we going to be delinquent? Unless we heed the Paris Declaration and focus on shared interconnected risks that trap households in poverty and sickness, we will not achieve basic goals of human development." As if responding to Stuckler's call for action, Ms Ann Keeling, Chief Executive Officer of the International Diabetes Federation, made the point that there is a weak civil society movement advocating the case of NCDs - and there is no outrage. "Solving the NCD problem will need concerted action by governments, civil society and private sector," Keeling said. As a response the NCD Alliance was formed in January 2009 as a coordinated civil society movement. The NCD Alliance consists of IDF, WHF, IUCC and IUATLD and together they cover more than 880 national associations in more than 170 countries (5). Listen to your development partners In spite of concerted efforts to bring all the international donors to the Conference, however, only a few bilateral donors committed time and resources to attend. The absence is of course open to interpretation, but two obvious reasons could be that in general, donors do not prioritise NCDs for the simple reason that they are not included in the MDGs; instead they focus on the established development goals. Keeling reminded the audience of the absence of the majority of the top 15 bilateral donors - of these only five were present (Denmark, Finland, Netherlands, Norway and Spain). In line with the Paris Declaration on Aid Effectiveness, one of her messages to the bilateral donors was: "Listen to your partners in developing countries as you said you would." The implicit message was of course that those partners will tell similar stories as the one Dr Tembu told from rural Kenya. Voices from the South Mozambique's Health Minister, Honourable Dr Paulo Ivo Garrido summed up his country's challenges for dealing with NCDs (photo: Jesper Westley).   The Health Minister of Mozambique, a country which has an HIV/AIDS prevalence of 15%, Honourable Dr Ivo Garrido spoke of the increasing burden of NCDs in his country. He mentioned increasing economic development in Mozambique as the leading factor for exposing Mozambicans to the risk factors leading to NCDs. Mozambique has taken action on this and included NCD components into the National Strategic Plan for Prevention and Control of Communicable Diseases. Yet, the list of challenges for dealing properly with this is extensive: lack of human resources, lack of health infrastructure and lack of involvement of international donors resulting in no budget, no resources and very little attention paid to the area. The State Minister for Health of Uganda, Honourable Dr Richard Nduhuura was more frank. He said, "Uganda is experiencing an epidemiological transition characterised by a sharp increase in the incidence of NCDs. This affects the most productive sections of our population with serious and adverse human, social and economic consequences at individual, community and national levels. Given current misconceptions in both public and donor circles we face a threat of a disastrous double epidemic of communicable and non-communicable diseases. If we are to reverse this trend we need to shift our thinking." Getting the facts right Dr Paul Fife, Director of the Department of Global Health and AIDS in Norad, represented one of the five bilateral donors present at the conference. He assured that when Norway will be on the WHO Board 2010-2013 they will use the opportunity to see how they can intervene strategically. Providing another bilateral donor's perspective, Mr Esben Sønderstrup, Chief Technical Advisor at Danida, explained the background for Danida co-hosting the conference: "We decided to co-host this conference in order to ignite the debate on what to do about the emerging burden of NCDs in developing countries. The conference confirmed what we already knew, but it did so from a multitude of angles which made the magnitude of the problem even clearer," he said. Referring to the concrete action points in his presentation he admitted that they knew from the beginning that it would be difficult to extract any concrete action directly from the conference. "But what Danida will do is to bring the problem of NCDs onto the health agenda in the countries where we work. Specifically, this means bringing it up in the annual review round with the health ministries and more importantly, arguing for its inclusion in the 5-year country programmes," he said. Concluding his presentation Mr Sønderstrup said, "There are many challenges in fighting NCDs - but there has always been many challenges in public health. Donors cannot solve the problem, ultimately the developing countries must take responsibility - and then we can assist. But we have to start somewhere, and getting the facts right is not a bad place to start." Whether the pronunciation or communication difficulties explain the absence of the majority of bilateral donors, those present were left with little doubt that NCDs are indeed a development issue which should be taken seriously in future poverty reduction strategies.   Background material and presentations from the conference are available here. References 1. The conference was formally supported by the World Bank Group, the International Diabetes Federation, the World Heart Federation, the International Union against Cancer, NORAD (Norwegian Agency for Development Cooperation), the Norwegian Directorate of Health and the Danish National Board of Health. 2. WHO The Global Burden of Disease 2004. 3. Catastrophic spending is defined as spending more than 30% of the household income on health expenditures. Impoverishment is defined as moving from above poverty line to below during year. 25% of those who suffered from CVD risked catastrophic spending compared to 5% among those who had a different diagnosis than CVD. Similarly, 10% fell into impoverishment compared to 2%. (link to presentation + Source: Mahal et al 2010; National Sample Survey) 4. http://www.ncbi.nlm.nih.gov/pubmed/20209000 5. IDF=International Diabetes Federation; WHF=World Heart Federation; IUCC=International Union Against Cancer; IUATLD=International Union Against TB and Lung Diseases.

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