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The Road to a Global NCD Agenda
(and How to Keep a Smile
Off Big Tobacco's Face)
Thomas J. Glynn, PhD
American Cancer Society
Washington, DC
USA
Preaching to the Converted
Singing to the Choir
Carrying Coals to Newcastle
Therefore, my primary aim
today is to:
o Stimulate a discussion around the
realities of the NCD issue, and
o Stimulate discussion about potential
strategies to address NCDs
The presentation will be in four parts:
1) Pontificating about the importance of the
NCD issue;
2) then, Equivocating about the importance of
NCDs in relation to tobacco control;
3) and then Vacillating about both and
focusing on the need for a unified pandisease, pan-risk factor front in addressing
NCDs;
4) and, finally, Pontificating again, about
potential strategies in confronting the NCD
issue.
When we talk about
NCD risk factors, we
are essentially talking
about the three issues
Noncommunicable Diseases
4 Diseases, 4 Modifiable Shared Risk Factors
Total deaths around the world:
58 million
Total deaths around the world:
58 million
Deaths from noncommunicable
diseases around the world:
35 million
Total deaths around the world:
58 million
Deaths from noncommunicable
diseases around the world:
35 million
Deaths from noncommunicable
diseases in developing
countries:
28 million
Total deaths around the world:
58 million
Deaths from noncommunicable
diseases around the world:
35 million
Deaths from noncommunicable
diseases in developing
countries:
28 million
Deaths from noncommunicable
diseases in developing
countries which could have
been prevented: an estimated
14 million
Noncommunicable Diseases
Mortality among men and women aged 15-59
years (2004)
Noncommunicable Diseases
Projected Deaths in 2015 and 2030
Noncommunicable Diseases
Death trends (2006-2015)
2005
2006-2015 (cumulative)
NCD
deaths
(millions)
NCD
deaths
(millions)
Trend: Death
from infectious
disease
Trend: Death
from NCD
Africa
10.8
2.5
28
+6%
+27%
Americas
6.2
4.8
53
-8%
+17%
Eastern
Mediterranean
4.3
2.2
25
-10%
+25%
Europe
9.8
8.5
88
+7%
+4%
South-East Asia
14.7
8.0
89
-16%
+21%
Western Pacific
12.4
9.7
105
+1
+20%
Total
58.2
35.7
388
-3%
+17%
WHO projects that over the next 10 years, the largest increase in
deaths from cardiovascular disease, cancer, respiratory disease
and diabetes will occur in developing countries.
(WHO Chronic Disease Report, 2005)
Total
deaths
(millions)
Geographical regions
(WHO classification)
Noncommunicable Diseases
Oil and gas price spike
Retrenchment from globalization
Asset price collapse
NCDs
Fiscal crisis
Flu pandemic
Food crisis
Infectious disease
http://www.weforum.org/pdf/globalrisk/globalrisks09/global_risks_2009.pdf
World Economic Forum: Global Risk Assessment 2009
Noncommunicable Diseases
Macro-economic Impact: Lost National Income
2005
2006-2015 (cumulative)
Lost national income
(billions)
Lost national income
(billions)
Brazil
3
49
China
18
558
India
9
237
Nigeria
0.4
8
Pakistan
1
31
Russian Federation
11
303
Tanzania
0.1
3
Countries
WHO: "Heart disease, stroke and diabetes alone are estimated
to reduce GDP between 1 to 5% per year in developing
countries experiencing rapid economic growth"
(WHO Chronic Disease Report, 2005)
Lost national income from
premature deaths due to
heart disease, stroke and
diabetes
Global Burden of Cancer
• 12.7 million new cases of cancer in
2008
• 7.6 million cancer deaths in 2008
• 24.6 million people living with cancer
throughout the world
Globocan 2008 (IARC), Parkin et al.
Global Cancer Incidence
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
ca
l
C
er
vi
er
Li
v
Lu
ng
B
re
as
C
t
ol
or
ec
ta
l
St
om
ac
h
Pr
os
ta
te
0
Globocan 2008 (IARC)
Global Cancer Mortality
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
er
ol
or
ec
ta
l
B
re
Es
as
t
op
ha
ge
al
C
er
vi
ca
l
C
Li
v
Lu
ng
St
om
ac
h
0
Globocan 2008 (IARC)
Current Burden of Cancer
• 56% of new cancer cases occur in
developing countries
• 63% of cancer deaths occur in developing
countries
• There are significant differences in the
pattern of cancer from region to region
• For example, cervical and liver cancers are
more common in developing countries;
prostate and colorectal cancers in
developed countries
Globocan 2008 (IARC)
Most Common Cancers, Developing
World
Male
Lung – 612,544
Stomach – 466,859
Liver – 440,654
United States
1. Prostate
2. Lung
3. Colorectum
Female
Breast – 691,281
Cervical – 452,902
Lung – 271,954
United States
1. Breast
2. Lung
3. Colorectum
Globocan 2008 (IARC)
Deadliest Cancers, Developing
World
Male
Lung – 539,035
Liver – 402,862
Stomach – 353,540
United States
1. Lung
2. Prostate
3. Colorectum
Female
Breast – 268,879
Cervical – 241,724
Lung – 239,013
United States
1. Lung
2. Breast
3. Colorectum
Globocan 2008 (IARC)
Cancer Cases and Deaths
Global Economic Burden of
Cancer = US $895 Billion/
1.5% of Global GDP
Source: American Cancer Society/LiveStrong Foundation, 2010
Just before the end of
the Pontificating phase, a
word about why NCDs
have become, so
recently, a significant
global issue...
Transitions
• Demographic Transition: A change in the
population dynamics of a country as it moves
from high fertility and premature mortality
rates to lower fertility and premature
mortality rates
• Epidemiologic Transition: A transition from
predominance of infectious diseases to
chronic, degenerative, or man-made
diseases; also a transition from cancers
caused by infectious agents to those related
to “modifiable” risk factors
Transitions
* Growing wealth and economic opportunity,
better nutrition and housing,
safer food and water, Improved hygiene and
sanitation, changes in reproductive practices,
and increased use of antibiotics and vaccines
have led to ...
* Better control of communicable diseases,
reductions in childhood mortality, increases in
life expectancy, and ultimately ...
Growing and aging populations.
Evolution of Population Pyramid
United States 1950-2050
Men
The population pyramid for China unfolds over a 100
(1950-2050) year period and the aging of the
population becomes quite obvious.
For the period 1950 to 1995 the pyramid is based on population estimates
of the UN Population Division; the data for 2000 to 2050 are from the most
recent medium variant UN population projection.
World Population
Population (2005)
6.454 billion
3.245 Billion
3.209 Billion
World Population
Population (2030)
8.130 billion
4.068 Billion
4.062 Billion
Transitions
• Simultaneously, the forces of globalization have
facilitated the broad and aggressive marketing of
tobacco products, resulting in the growth of
tobacco–use and tobacco-caused morbidity and
mortality (1.25 billion smokers).
• And increased consumption of high–calorie foods,
driven by a global food industry, along with
reductions in physical activity, caused by changes in
the workplace, are contributing to increases in
overweight and obesity and the diseases associated
with them (1.6 billion overweight, 1 in 4, 400 million
obese).
- Tobacco Atlas 3rd ed; WHO
And, less physical activity
Beijing ca 1980
Beijing today
Transitions
Population
Growth
WHO, Global Health Risks, 2009
WEF: Global Risks Landscape 2010
droughts
terrorism
Now, on to some
Vacillation
Having made the argument that
NCDs should be at the top of the
global health agenda, is there danger
that tobacco - the risk factor
common to the four major NCDs and
the cause of more death and
disability than any other - will be
swept into the background?
"Don't Forget Tobacco"
Steven A. Schroeder, M.D., and
Kenneth E. Warner, Ph.D.
N Engl J Med 2010; 363:201-204
The Disease Consequences
of Tobacco Use Are
Universal
Tobacco Related Cancers
•
•
•
•
•
•
•
•
•
Oral cavity and pharynx
Esophagus
Larynx
Lung, trachea and bronchus
Urinary bladder
Renal pelvis
Uterine cervix
Pancreas
Kidney
Tobacco Related Cardiovascular
Diseases
•
•
•
•
•
•
Hypertension
Ischemic heart disease
Atherosclerosis
Pulmonary heart disease
Aortic aneurysm
Stroke
Tobacco Related Respiratory Diseases
•
•
•
•
Chronic bronchitis
Emphysema
Asthma
Pneumonia
Tobacco Related Pediatric Diseases
• Low birth weight
• Respiratory distress
syndrome
• Sudden infant death
syndrome
Secondhand Tobacco Smoke
Problems
• Heart Disease
• Lung cancer
• Asthma attacks
• Bronchitis and
pneumonia
(especially children)
• Coughs and croup
(especially children)
• Middle ear infections
(children)
Economic Effects of Tobacco Use
By 2010, the WHO estimates the
annual global cost of tobacco to be
US$500 billion – a figure higher than
the GDP of 174 of 192 UN members
Smoking-related costs can
Smokingcontribute up to 15% of total healthhealthcare costs in developed countries
Japanese male smokers, for
example, incur 11% more medical
costs than never smokers and have
increased inpatient medicalmedical-care
costs 33% higher in smokers than
never smokers
Economic Effects of Tobacco Use
(continued)
As much as ten percent of family
income in some parts of the world is
spent on tobacco, limiting needed
expenditures on food, clothing,
education, and shelter
A 1996 study – 10 years ago –
estimated that total annual medical
and social costs of tobacco use in
Hong Kong were oneone-quarter of the
total healthcare budget – and
prevalence has risen since then
For nearly 50% of the world’s
population, a pack of Marlboros costs
approximately half of a family’s daily
income
The Tobacco Issue is not "Solved" or "Over"
- Progress has been made, but ...
o Tobacco Use Reductions in HighIncome Countries Have Slowed in
Recent Years
o And...
millions
Tobacco deaths in the Industrialized
and Developing World, 2000 and
2030
10
9
8
7
6
5
4
3
2
1
0
Industrialized
countries
Developing
countries
2.1
3
7
2.1
2000
2030
While tobaccorelated deaths will
only increase
slightly in the
industrialized
world during the
next 30 years,
they will more
than triple in the
developing world.
“Tobacco use is unlike other
threats to global health. Infectious
diseases do not employ
multinational public relations firms.
There are no front groups to
promote the spread of cholera.
Mosquitoes have no lobbyists.”
WHO Zeltner Report, 2000
Why Hasn’t Tobacco Control
Received the Global Attention it
Needs?
1. Tobacco use is viewed as a
personal choice and a personal
failing
2. Most victims of tobacco-related
disease die and disappear quickly
3. Families and victims are often
ashamed to discuss their tobacco
use
4. The tobacco pandemic has
developed slowly and insidiously
Why Hasn’t Tobacco Control Received
the Global Attention it Needs?
(continued)
5. Tobacco is old news
6. No strong tobacco control
advocacy groups have
arisen
7. The global effects of
tobacco use – health and
economic – are not well
known
8. The multinational tobacco
companies have controlled
the playing field.
2 million
1 million
0
3 million
4 million
High blood pressure
High blood glucose
Physical inactivity
Unsafe sex
Underweight
High cholesterol
Overweight and obesity
Alcohol use
Indoor smoke from solid fuels
6 million
Tobacco use
5 million
Unsafe water, sanitation, hygiene
Low fruit and vegetable intake
Sub-optimal breastfeeding
Urban outdoor air pollution
Occupational risks
Vitamin A deficiency
Zinc deficiency
Unsafe health care injections
Iron deficiency
Illicit drug use
Unmet contraceptive need
Global climate change
Lead exposure
Child sexual abuse
New perspectives on the NCD problem
Attributable deaths in developing countries by risk factor
7 million
Millennium Development Goals
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6
Goal 7
Goal 8
Eradicate extreme poverty and hunger.
Achieve universal primary education.
Promote gender equality and empower women.
Reduce child mortality.
Improve maternal health.
Combat HIV/AIDS, malaria and other diseases.
Ensure environmental sustainability
Develop a global partnership for development.
Tobacco control relevant to most aspects of
development
Tobacco control is relevant in achieving each of the eight
United Nations Millennium Development Goals (MDG)
• Health development:
Non-communicable diseases
(NCDs),
TB, HIV/AIDS, maternal and
child health
• Economic development:
poverty reduction, health
systems financing, food
security, environmental
sustainability, rural/agricultural
development
• Social development:
gender equality, child
labour/education
Now, finally, some
EQUIVOCATION
Three Threats to
Raising NCDs to the
Top of the Global
Health Agenda:
1. The Quandary
Properly and Effectively
Addressing NCDs will not
Work if a Disease and/or Risk
Factor Hierarchy, or Caste
System, is Allowed to Develop
Tobacco control relevant to most
aspects of development
Tobacco control is relevant in achieving each of the eight
United Nations Millennium Development Goals (MDG)
• Health development:
Non-communicable diseases
(NCDs),
TB, HIV/AIDS, maternal and
child health
• Economic development:
poverty reduction, health
systems financing, food
security, environmental
sustainability,
rural/agricultural development
• Social development:
gender equality, child
labour/education
World Health Statistics 2007, World Health Organization, https://www.who.int/whosis/whostat2007_10highlights.pdf
Global NCD Coalitions
o NCDnet
o NCD Alliance
o Global Alliance for Chronic Disease
and many other organizations (e.g.
C3, OxHa, GI, PHII, BI, IDRC, etc.)
2. The Koplan-Yach Cautionary Principle:
Arguments Against an NCD Focus
o "Life expectancy in our country is too short
to worry about NCDs"
o “ NCD data only apply to high-income
countries"
o "The healthcare system in our country is in
disarray, so we can't deal with NCDs"
o "We have more immediate problems, both
health-related and political, to address"
o "NCD data are merely projections, so
maybe they will not come to pass"
2. Koplan-Yach Cautionary Principle:
(continued)
o "Our Health Ministry and politicians are not
aware of the scope of the NCD issue"
o "NCDs are the diseases of the rich, not the
majority of people in my country"
o "NCDs are the fault of the individual, so
should receive less attention"
o "NCDs are too expensive to prevent and
treat"
o "We do not have the experience and
knowledge in my country to prevent and
treat NCDs"
3. The Global Health/Development
Bureaucracy
The NCD movement will need to
carefully maneuver through the global
health/development bureaucracy,
which can be both a help and a
hindrance.
UN NCD High level meeting
By the end of 2010
Modalities
resolution
CARICOM
Pres of GA
Next month?
GA Member
states
2 co-facilitators (one
likely to be
CARICOM)
Office of Sec General
Draft
outcome
document
UN agency – WHO?
Report on NCDs at
GA 65th session
USG
Civil
society
UNDESA
Dept for General
Assembly and Conf
management
2011
NCD Summit – Sep
2011
Side events
Final
outcome
document
“A public health
emergency in
slow motion”
Ban Ki-moon,
UN Secretary General
But...a final, brief
PONTIFICATION
The Potential for Success
in Addressing NCDs on a
Global Scale abounds...
1. Global NCD Coalitions
o NCDnet
o NCD Alliance
o Global Alliance for Chronic Disease
and many other organizations (e.g.
C3, OxHa, GI, PHII, BI, IDRC, etc.)
2. Strength of the Data/Science
3. Lessons Learned from the
Communicable/Infectious
Disease Experience
4. Specificity of the NCD
Needs/ Goals, e.g.
• Successful September, 2001 U.N. NCD Conference
• Governments to be accountable/measured on NCD
plans/actions
• Globally agreed approaches to NCD
prevention/treatment/care
• Specific resources allotted to deliver NCD interventions
• NCDs in MDG successor goals
• Provide policymakers with NCD evidence - health and
economic
• Elevation of NCDs on national/regional health agendas
• Expanded NCD research
“Richard Doll was both a great doctor and the greatest
epidemiologist of our time.” Guardian obituary, 2005
(Photo at BMJ press conference on 5050-year results, 2004)
©2009 American Cancer Society, Inc. No.0052.19