The Long Tail of Global Health Equity: Tackling the Endemic NCDs of the Bottom Billion

by Jeremiah Norris – Senior Fellow, Hudson Institute

Introduction – On March 2 and 3, a Conference was held at Harvard Medical School on a subject of emerging importance to the global health community.  It was hosted by Partners in Health, the NCD Alliance, the Harvard Medical School, Brigham and Women’s Hospital, the Harvard School of Public Health, Harvard Global Health Equity Initiative, the Global Taskforce on Expanded Access to Cancer Care in Developing Countries, and the Medtronic Foundation.   The main purpose of the Conference was to galvanize support and advocacy for the upcoming UN High-Level Meeting on NCDs in September 2011.  While there were more than 20 speakers, this blog will only cover comments from the Key Note Address, those from the Sabin Vaccine Institute, the Chair of the NCD Alliance, and the Closing Presentation. These will give the reader a sense of the entire proceedings.

The Meaning of Long Tail – It has several meanings, one being that NCDs have a legacy with infectious diseases of the 15th Century, [as well as centuries lost to antiquity in the Pharaonic era, e.g., schistosomiasis] while another is neglected tropical diseases (NTDs) have co-morbidities as NCDs, e.g., malaria can lead to an enlarged spleen and the need for chronic care, and still another is that past successes in the reduction of NTDs have now migrated patients onward to NCDs and a continuum of prevention and treatment.  Thus, when it comes to patients’ comprehensive health profile, it is a false dichotomy to separate one from the other, the long tail is a way to view the next generation of health services.

1.  Key Note Address – This was delivered by Dr. Paul Farmer of Partners in Health, and Chair, Department of Global Health and Social Medicine, Harvard Medical School.  His main points:

  • He started by comparing MDR-TB in poor countries, when earlier both WHO and PAHO said this was an untreatable, terminal condition. Dr. Farmer showed how it could be treated with high quality medicines in Peru, saving the lives of many patients. He used this example to say: this is where we are with NCDs because many believe they are too expensive to treat in poor people.
  • He discussed how lower drug prices, negotiated by the Clinton Foundation, have made 2nd line therapies for drug resistance patients more affordable.
  • He continued this point by referring to ARV prices some 15 years ago, saying there was almost nothing until The Global Fund to Fight HIV/AIDS, TB and Malaria became the first to show that it was possible to provide ARVs to patients at affordable prices.
  • On addressing NCDs, he commented that there are a lot of ‘nay-sayers’ in the environment, talking about the high costs for NCDs.  But just as they lost this battle on AIDS, and MDR-TB, they will also lose it on NCDs, also. We have to improve drugs and diagnostics for NCD, he said.
  • On the cost for NCDs, he offered the notion that we really don’t know how much it will cost to treat, say, CVD patients. He went on to say that prevention is much less costly than treatment in any case.
  • Dr. Farmer uses a community based model in his projects in Haiti and Rwanda and recommended that a similar model would be needed for NCDs. In this scheme, hospitals, referral centers, and clinics are linked in a continuous chain of prevention and treatment modalities.
  • Lastly, he said that partnership is the only way to move the NCD effort forward.

2. Dr. Peter Hotez, President of the Sabin Vaccine Institute and professor at George Washington University’s Medical School, spoke on the relationship between NTD and NCDs. He said that 1.4 billion poor people are affected by NTDs, and that India losses $1 billion in agricultural production annually from them. He commented that a NTD like schistosomiasis can lead to bladder cancer, urinary tract infections, and liver flukes. These are chronic conditions. His point was that there is common ground between NTDs and NCDs; thus a continuum of care from one to the other. So, let’s not silo NTDs.

3. Dr. Ann Keeling, Chair, NCD Alliance addressed the ‘4 x 4’ goals of NCDs. By this, she meant the importance of focusing on only four NCDs (CVDs, cancer, diabetes and upper respiratory diseases) against four risk factors (tobacco; alcohol, diet, and physical inactivity). She went on to say that one-third of cancer deaths occur with people under the age of 60, and that 70% of cancer mortality is in low and middle income countries.  The NCD Alliance is composed of four federations, and 900 Associations around the world. It runs hospitals and clinics and is into patient treatment for NCDs. Lastly, she wanted the audience to understand that “we are already on the MDGs as the diseases listed therein have NCD co-morbidities, e.g., 15% of TB patients in India have diabetes. She ended by saying that “we want the UN to be a catalyst for NCD discussions in September and for it to promote international cooperation and coordination, then to initiate a concise action plan for the future”.  In that regard, she posited, “we are not looking for a new Global Fund but we are looking for leadership from the private sector”.

4.  Closing Presentation – It was chaired by Dr. Farmer. A slide was put up showing the “Boston Statement on NCDs”. It read in one part: “We call on all UN member state Heads of Government, Heads of State to unite at the September 2011 UN Summit on NCDs and take urgent action to address the millions of premature deaths and widespread suffering caused by NCDs amongst the world’s billion poorest people by …”

It then lists a number of ways in which this can be done, e.g.: integrating NCDs in the successor goals to the MDGs after 2015; recognizing that the social determinants of health are relevant to NCDs;  the linkages between infectious and noncommunicable diseases require integrated prevention, diagnosis, treatment and care; and that NCDs impose costs on the economy, such as lost productivity among people of working age and decreased rates of economic growth, which is why they must be addressed.

Analysis – The Conference framed the NCD issue for the upcoming UN High-Level Meeting on NCDs in September. The papers which were delivered, and the intellectual and institutional weight put behind them by Dr. Paul Farmer and the Harvard Medical School, should advance the NCD cause substantially. The Conference itself was a compelling statement which showed that NCDs in the Bottom Billion could indeed be prevented and treated, often with far less costs than previously imagined.

Yet, NCDs also affect those population groups between the Bottom Billion and the top billion—perhaps 4 billion in total, largely comprising the working-age groups.  They cannot be left aside without risk to losing political support within the countries themselves for NCDs. Governments will have a difficult time explaining to population groups above the Bottom Billion why health aid on NCDs will be unavailable to the same population in which the majority of their labor forces and political steak-holders reside.

By sequestering the NCD problem to the Bottom Billion, advocates are in effect ‘siloing’ the issue, much as what happened with HIV/AIDS, TB and malaria. And by limiting the risk factors to four elements, they ignore the substantial risks posed by obesity, the adverse effects of biomass fuels for cooking in 50% of the world’s households, etc.

The limitation to the Bottom Billion also makes it difficult for major donors, such as USAID, to re-align their health portfolios, now locked into forward authorizations by the Congress on major extant programs, such as PEPFAR and the Global Health Initiative, over the next five years. It forces policy-makers in the bilateral, multilateral and private giving community to make choices on who will get health aid for NCDs and who will not, based on where they fall within distinct population groupings, disease and risk categories. Since people in the Bottom Billion are poor because they don’t have money, and they don’t have money because they don’t have jobs, the vast majority of  resources to fund NCDs for a population that lives on $1 a day will necessarily have to come from the currently cash-strapped donor community, but certainly not through “means-testing”.

Dean Julio Frenk of the Harvard School of Public Health recommended to participants that access to NCD services should be a “universal human right”. But if this is only for the Bottom Billion, can such access be less of a right for the Middle Billions!

The Harvard Conference was a major step forward in moving NCDs onto the agenda of the global health community. Its limitations, though, can—and most probably will, be seen as inadvertent forms of discrimination.  There is no asterisk on the UN Universal Declaration on Human Rights to denote that exemptions are permitted to its provisions.

The NCD Alliance would want to avoid that impression at all costs as it moves forward to the September UN meeting.  NCDs need to be about us rather than about them.

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