The U.S. Government and Global Non-Communicable Diseases
Non-communicable diseases (NCDs) are the leading causes of death and disability globally, killing more than three in five people worldwide and responsible for nearly half of the global burden of disease. NCDs cause and perpetuate poverty while hindering economic development in low- and middle-income countries. Identified as “one of the major challenges for sustainable development in the twenty-first century,”1 NCDs have received greater attention worldwide and within the United States in recent years, as global efforts to tackle this growing health challenge have become more organized and prominent.
The U.S. government (USG) is increasingly engaged in addressing the challenge of NCDs in low- and middle-income countries, as several USG agencies and departments have begun to integrate activities targeting NCDs and its risk factors in the course of other global health efforts, particularly through technical assistance and research activities. However, to date, the USG response to NCDs is much smaller in scale and approach than its main global health efforts.
Current Global Snapshot
NCDs are not a new problem, having long been of concern in developed countries; they are, however, of increasing concern in developing countries because of their transition from low-income to middle-income status, the influence of globalization on consumption patterns, and the aging of populations.3
Mortality/morbidity: NCDs cause nearly two-thirds (63%, more than 36 million) of all annual deaths5and are among the leading causes of preventable illness and related disability.6 Cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes (see Figure 1) account for about 80% of these deaths. Other NCDs include: diseases causing blindness or deafness, birth defects, mental and neurological disorders (including Alzheimer’s disease), and renal and autoimmune diseases.7
|Figure 1: NCDs Accounting for Most Global Deaths from NCDs8|
|CVDs, the number one cause of death globally (mainly from coronary heart disease and stroke), can be mostly prevented by addressing risk factors; these include tobacco use, unhealthy diet and obesity, physical inactivity, and diabetes.|
|Cancer||With lung, stomach, liver, colon, and breast cancer causing most cancer deaths, behavioral and dietary risks include high body mass index, lack of physical activity, low fruit/vegetable intake, and tobacco and alcohol use. Viral infections (e.g., Hepatitis B and C viruses; Human papillomavirus) are also causes of cancer.|
|Chronic respiratory diseases||These are chronic diseases of the airways and other structures of the lung; among the most common are asthma and chronic obstructive pulmonary disease (COPD, an incurable, life-threatening lung disease that interferes with normal breathing). COPD is caused primarily by tobacco smoke (firsthand use or secondhand smoke).|
|Diabetes||A chronic disease that occurs when the body cannot effectively regulate blood sugar, uncontrolled diabetes can lead to death as a consequence of high fasting blood sugar. Adult-onset diabetes (type 2) can be prevented or onset delayed by addressing risk factors (e.g., healthy diet, physical activity, normal body weight).|
Affected groups and regions: The impact of NCDs is growing rapidly, affecting people of all ages and income levels in all regions of the world but particularly in developing countries, where the problem is expanding most and where the vast majority (80% or 29 million) of all NCD deaths occur (see Figure 2). Though NCDs are often associated with older people, more than 14 million deaths caused by NCDs each year occur before the age of 70 (“premature deaths”). Nearly all (86%) of these premature deaths occur in developing countries. For all regions except Africa, NCDs are now the leading causes of death; it is projected that by 2030, this will also be the case in Africa.9 With the growing incidence of NCDs and the ongoing challenge of tackling infectious diseases, some regions like Africa are facing a “double burden” of disease.
Economic cost: The growing burden of NCDs exacts an economic cost, as people are less productive, less able to work for more years of their lives, and die prematurely. If they continue their upward trend, NCDs are estimated to cause a cumulative loss of output of $47 trillion between 2011 and 2030.10
|Figure 2: NCD Indicators by Region11|
|WHO Region||Mortality Rates by Cause: NCDS||Prevalence of Smoking||Alcohol
|Age-Standardized, Deaths per 100,000 Population, 2008||Any Tobacco Product
Adults Aged Above 15 Years, %, 2009
Above 15 Years, Liters of Pure Alcohol per Person/Year, 2005
Above 20 Years
|NOTES: LI means low income, LMI means lower middle income, UMI means upper middle income.|
Risk factors for NCDs include behavioral, environmental, economic, and other social determinants of health.12 Behavioral risk factors, such as tobacco use, unhealthy diets, physical inactivity, and harmful use of alcohol, are associated with higher health costs and reduced productivity. Other risk factors include: growing urbanization, which contributes to changing physical activity and dietary patterns as well as pollution; poverty and growing inequalities in wealth (particularly in low- and middle-income countries), which affects access to affordable, nutritious food; and indoor air pollution, which is a more frequent problem in developing countries where inefficient cooking stoves are often used for indoor cooking/heating and result in smoke exposure. Risk for NCDs also varies by age, sex, and genetics.
A range of simple, cheap, and/or cost-effective interventions exist for addressing NCDs, including:13
- Prevention interventions that target modifiable risk factors and promote healthy living, such as: education about NCDs and their risk factors, efforts to prevent and reduce the use of tobacco and the harmful use of alcohol, and creating environments that support increased consumption of fruit and vegetables, reduced salt intake, and increased physical activity.
- Measures to support effective treatment and quality care (with particular attention to the needs of the poor and most vulnerable, including those with major chronic diseases14), such as: building the capacity of health systems and health workers to respond effectively to NCDs and ensuring the availability and affordability of medicines and basic technologies.
- Efforts to raise the priority accorded to NCDs at the global and national levels (i.e., leadership and country ownership), to integrate NCD prevention and control into governments and multilateral institutions’ policies, plans, and programs, and to promote legislative, regulatory, and fiscal measures that discourage the use of tobacco and support health living.
Additionally, multisectoral and other partnerships for the prevention and control of NCDs support more holistic efforts by involving public health implementers as well as education, business, and other stakeholders in efforts.
In 2011, the United Nations (UN) held the High-level Meeting (HLM) on the Prevention and Control of NCDs. Only the second time that the UN General Assembly had met to discuss a specific health issue (the other being HIV), the HLM led to greater global attention to NCDs and called for new global targets and an action plan for addressing NCDs. Among the targets subsequently outlined in the WHO Global Action Plan for the Prevention and Control of NCDs, 2013–2020 (WHO Global Action Plan15) and endorsed by the World Health Assembly16 in 2013 are:
- Reducing deaths from NCDs by 25 percent.17 Achieving this target, which is often referred to as the “25 by 25” goal, is the focus of the roadmap laid out in the WHO Global Action Plan.
- Reducing the prevalence of current tobacco use in persons aged 15+ years by 30 percent. This target builds upon the goals of the 2003 Framework Convention on Tobacco Control (FCTC): reducing demand for and supply of tobacco.18
- Reducing the harmful use of alcohol by at least 10% (as appropriate, within the national context). Adopted in 2010, the WHO Global Strategy to Reduce the Harmful Use of Alcohol describes relevant policy options and interventions.19
- Reducing the prevalence of insufficient physical activity by 10%. Though a decade old now, the 2004 WHO Global Strategy on Diet, Physical Inactivity, and Health assigns responsibilities and sets objectives for improving physical health.20
- Achieving an 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities.
Additionally, the WHO Global Action Plan stresses that other NCDs are “often associated with mental disorders and other conditions and that mental disorders often coexist with other medical and social factors,” so the plan should be implemented “in close coordination with the WHO Global Mental Health Action Plan, 2013–2020.”21
U.S. Government Response
Though not an area of major focus historically, USG attention to NCDs has grown recently. USG engagement in global NCDs has largely included health diplomacy, scientific research, and technical assistance, often drawing on the USG’s experience with NCDs domestically, as well as some funding. For example, the USG played an important role in international efforts to outline global priorities for and monitor country efforts to reduce the impact of NCDs.
Structure and Approach
Although there is no USG program that specifically focuses on NCDs in low- and middle-income countries, NCDs and their risk factors are sometimes addressed as part of other USG global health activities, such as maternal, newborn, and child health (MNCH), HIV, and nutrition efforts.22 USG agencies supporting such efforts include the Centers for Disease Control and Prevention (CDC), the National Institutes for Health (NIH), the Department of State, the U.S. Agency for International Development (USAID), the Department of Health and Human Services’ Office of Global Affairs (OGA), and the Millennium Challenge Corporation (MCC).
- CDC: CDC reports working on global NCDs for over 20 years through efforts that address disease surveillance and epidemiology, identify risk factors and evidence-based prevention strategies, use data to increase effective public health action, and increase country capacity and skill development. Efforts address issues like cervical cancer, clean cookstoves, epidemiology and training focused specifically on NCDs, hypertension, promoting physical activity, and tobacco control.23
- NIH: Several NIH Institutes conduct NCD research, including globally-focused research as members of the Global Alliance for Chronic Diseases24 (an international public-private partnership that facilitates research collaborations focused on NCDs), and support NCD surveillance and training programs, strengthening local capacity and inform countries’ NCD policies.
- Department of State: State’s efforts emphasize public-private partnerships with a focus on cancer and smoke exposure.25
- USAID: The agency’s approach to NCDs emphasizes investments in health systems strengthening, with existing global health efforts “building the foundation upon which future NCD efforts can be based.”26 In a few cases, the agency has identified cost-effective interventions to address NCDs, such as integrating tobacco screening and counseling into antenatal care programs.
- OGA: The office leads HHS engagement with multilateral partners and coordinates HHS operating divisions’ contributions to achieving the department’s NCD objectives.27
- MCC: As a U.S. government corporation focused on promoting economic growth and reducing poverty in low- and middle-income countries, MCC supports health projects addressing NCDs in certain compact countries.28
U.S. Government Funding
Currently, funding specifically for addressing NCDs in low- and middle-income countries is not designated by Congress, nor is such funding easily identifiable at the agency level. Where NCD funding is identifiable, it remains relatively small. For example: In 2012, NIH’s Fogarty International Center awarded $14 million to 15 research institutions to fund training in research areas related to NCDs in developing countries.29 Beginning in 2008, MCC provided about $40 million to address NCDs in Mongolia over the five-year life of this country’s MCC compact.30 Funded at $12.2 million in FY 2012, CDC’s Field Epidemiology Training Programs (FETPs) prepare trained public health workers to respond to NCDs (among other things).31
Without significant efforts to address the key risk factors and underlying social determinants driving NCDs, the economic and social toll of burgeoning numbers of people affected by NCDs in developing countries will continue to grow. Many public health experts stress the importance of early intervention in efforts to reduce NCDs, as they generally develop over time and are more difficult – and costly – to address later. Some have called for dedicated USG funding for NCDs, while others say there is a need to prioritize funding for existing global health programs during a time of constrained budgets. Looking forward, opportunities and challenges facing policymakers include: balancing the need to address a growing NCD problem with the need to finish the infectious diseases agenda; deciding how the USG may best contribute to global NCD efforts (in light of its experience in addressing NCDs domestically), whether through health diplomacy efforts, technical assistance, a targeted NCD program and funding, and/or reshaping existing global health programs to also address NCDs (i.e., supporting health program platforms that can respond to multiple health challenges); supporting further research into the risk factors and drivers behind this growing challenge; accelerating research into and implementation of innovative solutions that address key risk factors and strengthen the capacity of health systems to respond to NCDs; and addressing trade and intellectual property concerns in order to buttress continuing NCD research and development efforts while expanding the availability of and affordable access to NCD medicines, diagnostics, and treatments in developing countries.
UN, Report of the United Nations Conference on Sustainable Development (Rio de Janeiro, Brazil, 20–22 June 2012), A/CONF.216/16 , 2012.
Some NCDs may be caused by viral infections, but the diseases themselves are not infectious nor transmissible. Though they are sometimes referred to as “chronic diseases,” NCDs are not distinguished by their duration. WHO, “Chronic diseases,” webpage, www.who.int/topics/chronic_diseases/en/; WHO, “Noncommunicable diseases,” fact sheet, March 2013.
IHME, The Global Burden of Disease: Generating Evidence, Guiding Policy, 2013.
WHO, Global action plan for the prevention and control of NCDs, 2013-2020, 2013.
WHO, “Cause-specific mortality: Disease and injury regional mortality estimates, 2000-2011, by WHO region,” Global Health Estimates website, 2013.
WHO, “Disease burden: WHO estimates for DALYs, 2000-2011,” Global Health Estimates website, 2013; UN, “Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases,” A/66/L.1, Sept. 16, 2011.
The 2008 WHO 2008-2013 action plan for the global strategy for the prevention and control of noncommunicable diseases : prevent and control cardiovascular diseases, cancers, chronic respiratory diseases and diabetes stated, “There are many other noncommunicable conditions of public-health importance. They include osteoporosis, renal diseases, oral diseases, genetic diseases, neurological diseases, and diseases causing blindness and deafness. Many of these conditions are the subjects of other WHO strategies, action plans and technical guidance and are therefore not considered directly by this plan. Similarly, mental health disorders are not included here despite the heavy burden of disease that they impose, as they do not share the same risk factors (other than the harmful use of alcohol), and because they require different intervention strategies.” Likewise, the 2013 WHO Global action plan for the prevention and control of NCDs, 2013-2020 acknowledged other NCDs of importance.
WHO: “Cardiovascular diseases (CVDs), fact sheet #317, March 2013; “Cancer,” fact sheet #297, Jan. 2013; “Chronic respiratory diseases,” webpage, www.who.int/respiratory/en/; “Chronic obstructive pulmonary disease (COPD),” fact sheet #315, Oct. 2013; “Diabetes,” fact sheet #312, Oct. 2013.
According to WHO, “In African nations, deaths from NCDs are projected to exceed the combined deaths of communicable and nutritional diseases and maternal and perinatal deaths as the most common causes of death by 2030;” see WHO, “Noncommunicable diseases,” fact sheet, March 2013.
D.E. Bloom, et al., The Global Economic Burden of Noncommunicable Diseases, World Economic Forum/Harvard School of Public Health, Sept. 2011.
WHO, Global status report on alcohol and health, 2011; WHO, World Health Statistics 2013, 2013; Irina A. Nikolic, Anderson E. Stanciole, and Mikhail Zaydman, Chronic Emergency: Why NCDs Matter, World Bank Health, Nutrition and Population Discussion Paper, July 2011.
UN, “Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases,” A/66/L.1, Sept. 16, 2011.
Robert Beaglehole, et al., “Priority actions for the non-communicable disease crisis,” The Lancet, April 6, 2011; WHO, Global action plan for the prevention and control of NCDs, 2013-2020, 2013; WHO, Global status report on noncommunicable diseases 2010, 2011.
WHO, Department of Chronic Diseases and Health Promotion website, http://www.who.int/chp/en/index.html
The plan includes a comprehensive monitoring framework for prevention and control of NCDs that outlines nine voluntary global targets for 2025 and 25 indicators for monitoring progress toward them. WHO, Global action plan for the prevention and control of NCDs, 2013-2020, 2013.
UN, “Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases,” A/66/L.1, Sept. 16, 2011.
Specifically, the 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases concerns premature mortality from noncommunicable diseases between ages 30 and 70. 66th WHA, “Follow-up to the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases,” WHA66.10, May 27, 2013.
Adopted by the World Health Assembly in 2003 and entered into force in 2005, the FCTC is the first international treaty negotiated under the auspices of WHO and addresses a number of areas related to tobacco, including “protection of public health policies with respect to tobacco control from the interests of the tobacco industry.”
WHO, Global strategy to reduce harmful use of alcohol, 2010.
WHO, Global strategy on diet, physical inactivity, and health, 2004.
Mental health disorders are themselves NCDs, but they are addressed separately by WHO through WHO, Mental health action plan, 2013-2020, 2013.
InterAction, “Non-Communicable Diseases,” Global Health Briefing Book, 2013.
CDC, “The Problem of Noncommunicable Diseases and CDC’s Role in Combating Them,” webpage, Sept. 16, 2011, www.cdc.gov/globalhealth/ncd/overview.htm; CDC, Global Health-Noncommunicable Diseases website, www.cdc.gov/globalhealth/ncd/.
NIH’s GACD members are the National Heart, Lung and Blood Institute (NHLBI), National Cancer Institute (NCI), National Institute of Mental Health (NIMH), and Fogarty International Center (FIC). GACD, “Who We Are,” webpage, http://www.gacd.org/about/history/whoweare.
For example, the Pink Ribbon/Red Ribbon partnership brings the USG’s global HIV/AIDS platform together with partners to increase the availability of cervical cancer screening and treatment, particularly for HIV-positive women who are at high risk, and promote breast cancer education programs in sub-Saharan African and Latin American countries, while the Global Alliance for Clean Cookstoves promotes the adoption of clean, efficient stoves and fuels in 100 million homes by 2020. State Department, “Pink Ribbon Red Ribbon Overview,” fact sheet, Sept. 2011; Global Alliance for Clean Cookstoves webpage, www.state.gov/s/partnerships/cleancookstoves/; OGAC, Pink Ribbon/Red Ribbon webpage, www.pepfar.gov/partnerships/ppp/prrr/.
Ariel Pablos-Mendez, “Delivering Quality, Affordable and Equitable Care to Improve Health,” USAID Impact Blog, 2011.
OGA, “Global Health Topics: Non-Communicable Diseases,” webpage, www.globalhealth.gov/global-health-topics/non-communicable-diseases/. The Global Health Strategy of the U.S. Department of Health and Human Services (2011) includes Objective 8, which aims to “Address the Changing Global Patterns of Death, Illness and Disability.”
For example, a health project focused on NCDs in Mongolia, whose country compact concluded in 2013; see MCC, “Mongolia Compact,” webpage, www.mcc.gov/pages/countries/program/mongolia-compact.
FIC, “$14M awarded for chronic disease research training through NCD-Lifespan program,” Global Health Matters, newsletter, Sept./Oct. 2012.
MCC, “Mongolia: Roads, Energy, Vocational Training, Health and Land Tenure,” country brief, Nov. 2013.
CDC, CDC Congressional Budget Justification FY 2014, 2013.