After Some Haggling, Negotiators for U.N. Chronic Disease Summit Reach Tentative Agreement

After a summer of negotiations whose slow pace and political gaming has drawn the ire of numerous health advocacy organizations, representatives of U.N. member states appear to have come to a compromise on a political declaration document for the 19 September U.N. high-level meeting on the prevention and control of on noncommunicable diseases (NCDs). The agreement was reached 2 September, according to World Health Organization (WHO) Assistant Director-General Ala Alwan, 2 days after diplomats returned from a month-long hiatus and only 2 weeks before the heads of state arrive in New York City to accept the declaration's provisions—somewhat watered down from an original version. Among them: a pledge to institute a global monitoring framework within the United Nations that will assess trends in diabetes, cardiovascular disease, respiratory disease, and cancer, as well as what individual countries are doing about them. It also includes a recommendation that the WHO director-general and U.N. secretary-general present specific recommendations for action by governments to reduce NCDs and risk factors to the General Assembly by the end of 2012.

The document is being prepared in advance for the U.N. meeting, which will gather heads of state to address the global NCD epidemic. It is only the second ever meeting of this stature to address a health issue, the first being HIV/AIDS in 2001. But given the mishmash of chronic diseases and risk factors and the current economic climate, even the most hopeful of health advocates didn't hope for a global fund such as that established for AIDS in 2001 following the summit. At the upcoming meeting, member states will adopt whatever document was prepared by the U.N. diplomats ahead of time and commit to the actions it states. There's still a chance, however, that some member states will contest it this week.

When negotiations started in June, the diplomats, who negotiate on all manner of U.N. declarations, were slow to come to the table with their proposals, according to Ann Keeling, chair of the NCD Alliance (NCDA), a coalition of more than 2000 NCD organizations from 170 countries, which has been close to the negotiations and was pushing for a document with more teeth. Because of this, a document was never released for public comment, as is normal procedure. A leaked, heavily annotated 5 August draft suggests that negotiations stalled partly because of the influence of food, tobacco, and drug industries, according to editors at the British Medical Journal who saw the draft, and partly because the global economic crisis leaves nations "allergic to agreeing to anything that looks like [committing] new resources," Keeling says. A few of the sticking points, adds Alwan, were how countries should be able to promote and provide access to medicines and diagnostics to their citizens and the question of how to set up a global monitoring system.

Funding for NCD prevention is everyone's question, but where exactly this will come from is still unclear as there is no provision for a designated funding system. Instead, WHO, supported by other U.N. agencies, will be tasked with working with member states to promote increased funding for health, some of which will come from the countries themselves and may include measures such as tobacco taxation. There is also a recommendation to look for funding through other governmental and regional channels. But there's no call that money, private or public, that is now allocated to infectious diseases and maternal health, for instance, be reallocated to NCD prevention. "Support that is given to low- and middle-income countries that need technical support should be given based on their own health priorities," Alwan says, priorities that countries are tasked with setting. The meeting's goal is intended to raise NCDs to the level of concern that these other diseases elicit.

Although Alwan says that WHO is pleased overall with the outcome document, the recommendation for the World Health Assembly to set targets such as salt reduction and tobacco taxation in 2012 isn't likely to please health advocacy groups such as NCDA. "We want a commitment made on the 20th of September, not in 2012," Keeling told ScienceInsider last week. But as the leaked draft document was described to ScienceInsider, countries weren't ready to commit just yet. According to Keeling, the United States, Canada, and the European Union in particular blocked specific commitments, such as pledges to restrict salt and tax tobacco by certain dates. NCDA described an earlier version of the negotiated document as a play-by-play of these solid commitments being "systematically deleted, diluted and downgraded" and replaced with "vague intentions to "consider" and "work towards," according to a 16 August letter from NCDA to U.N. Secretary-General Ban Ki-moon. A 30 August editorial in The Lancet added: "A major opportunity to advance global health is in danger of being lost" if substantive targets are not set and nations don't agree to be held accountable for meeting them.

A commitment to introduce regulatory food measures to reduce daily salt consumption to a given amount by a certain date, for instance, was removed by the European Union—despite the fact that many E.U. countries already enforce such regulations. A commitment to tobacco taxation was also removed, despite the fact that many nations have already agreed to do so under the WHO 2003 Framework Convention on Tobacco Control. Keeling calls the position "ridiculous. We know how to do this and I think it's completely immoral that [these countries are] arguing against this for the rest of world when they've done this to safeguard its own population."

But even if such targets must wait a year, Alwan says that WHO has already made a great step in that direction with its Global Status Report on NCDS 2010 that was released in April. This report analyzed the prevalence of NCDs and risk factors worldwide as well as country by country and recommended concrete strategies that countries could implement to reduce the burden of these diseases. This strategy was intended to help narrow the complex NCD issue by focusing on four diseases: diabetes, CVD, respiratory disease, and cancer, and four risk factors: tobacco, physical inactivity, alcohol, and diet.

Alwan says that the most important point is that the document and the preparations for the high-level meeting, which includes heads of state rather than just health ministers, have succeeded in raising political awareness of NCDs and "elevating NCD prevention from a health priority to a development priority. This is a great achievement," he says. He adds that now that links have been established to socioeconomic development, WHO hopes to see NCD reduction included in the U.N.'s future socioeconomic development goals. WHO's ideal goal is to reduce NCD rates by 25% by 2025.

Furthermore, the meeting should remove the stigma of NCDs, which are sometimes considered the result of unhealthy choices by weak individuals. "If this declaration is approved in coming few days, then this is considered recognition that you cannot control NCDs by simply educating people to follow healthy lifestyles," says Alwan, adding that the declaration as it stands has a strong emphasis on NCD prevention. "You need to have an environment that is conducive."

If publicity for NCDs was what WHO and health leaders were after with the meeting, they've certainly achieved that. Numerous government health sectors have already pledged to institute new strategies on NCDs, and advocacy organizations have called for strong action by the United Nations. Even TV chef Jamie Oliver jumped into the fray, calling for governments to move to make obesity a human rights issue.