The World Health Organisation (2013) defines NCDs as diseases not transferred from person to person and characterised by a slow progression and a long duration. This group includes but is not limited to cardiovascular and chronic respiratory diseases, diabetes and cancer. Although these diseases are different in nature and symptoms, their common feature is that the spread of NCDs is associated with poor diet and exercise habits, tobacco and alcohol use. Therefore, personal choices of people in regards to their lifestyle could lead to obesity, high blood pressure and high blood sugar which trigger the development of NCDs.
Nowadays non-communicable diseases are the leading cause of death worldwide resulting in two of every three deaths each year or 63% of all deaths (NCD Alliance 2011). There are various risk factors influencing the spread of NCDs: globalisation, urbanisation, international trade, changing eating patterns, global ageing, less active lifestyles and exposure to alcohol and tobacco. NCDs affect people in all countries and contrary to the belief that NCDs are more common in the developed countries, the developing world is witnessing a rise in NCDs as well. In 2008, approximately four out of five NCD deaths occurred in low- and middle-income countries (WHO, 2011a), up sharply from just under 40% in 1990 (Murray & Lopez, 1997). Moreover, NCDs are having an effect throughout the age distribution – already, one-quarter of all NCD-related deaths are among people below the age of 60 (WHO, 2011a). NCDs also account for 48% of the healthy life years lost (Disability Adjusted Life Years–DALYs)1 worldwide (versus 40% for communicable diseases, maternal and perinatal conditions and nutritional deficiencies, and 1% for injuries) (WHO, 2005a). According to the statistics NCDs cause more deaths than any other diseases and becoming more common and widespread than AIDS and infectious diseases. At the same time most NCDs are preventable and/or reversible unlike other diseases – with living a healthy lifestyle with plenty of physical activity and a balanced diet, reducing the intake of alcohol and giving up smoking.
Although an increase in NCDs and as a result higher morbidity and mortality rates started happening only recently, this issue attracts a lot of attention from national and international organisations. To understand whether NCDs have become a global priority we have to look back and see what has been done to address and prevent NCDs so far. Previously the effort has been put in reduction of poverty together with AIDS and malnutrition. Up until 2011 the only time when the United Nations held a meeting dedicated to a health related topic (HIV/AIDS) was in 2001. Undoubtedly the recent High-Level Meeting on NCDs in September 2011 shows how important the issue has become and that the measures have to be taken as soon as possible. After the meeting all 193 UN member states adopted a Political Declaration and agreed to develop and implement NCD policies in the next few years.
The Political Declaration analyses NCDs from an array of perspectives: inequalities, gender issues, socioeconomic status (including the vicious cycle whereby NCDs and their risk factors worsen poverty, while poverty contributes to rising rates of NCDs), the importance of the early origins of health, linkages with communicable diseases such as HIV (including strengthening health systems), and the impact of other contemporary issues such as climate change, food security and food prices on NCDs. This paper shows that non-communicable diseases are not a purely health issue but they involve every aspect of life and therefore dealing with only with medical side of the problem is not enough to eradicate the development of NCDs.
Similarly, WHO has created and has been implementing the 2008-2013 Action plan for the prevention and control of NCDs. The following programs are put into practice to minimise the risk factors associated with NCDs: anti-tobacco measures in line with the WHO Framework Convention on Tobacco Control, the WHO Global strategy on diet, physical activity and health aims to promote and protect health by enabling communities to reduce disease and death rates related to unhealthy diet and physical inactivity, the WHO Global strategy to reduce the harmful use of alcohol offers measures and identifies priority areas of action to protect people from harmful alcohol use. A varied selection of strategies shows the importance of tackling every risk factor of NCDs from the global health perspective and puts NCDs as a priority within the international framework. These measures prove that NCDs are an international health priority indeed and a lot of work has gone into preventing human deaths but health concerns is not the only problem of NCDs.
The 20th and 21st centuries have been characterised by dramatic changes in nutrition patterns due to urbanisation and globalisation processes. Processed and fast food poor in nutrients, vitamins and minerals but rich in calories, sugar, saturated fat and salt is sometimes cheaper than organic equivalents and is more appealing to consumers. (Hawkes, 2006). While people consume less healthy foods at the same time they do not exercise enough – modern life goes hand in hand with sedentary lifestyles, which have accompanied economic growth, the shift from agricultural economies to service-based economies, and urbanization in the developing world. Obesity contributes to the development of diabetes due to high blood sugar and some types of cancer as a result of not having a balanced diet. The International Diabetes Federation states that approximately 285 million people are diabetic and the figure is likely to grow in the next 20 years. This total is expected to rise to 438 million by the 2030s (WHO 2010). The same prediction is made about cancer: for example, over 12 million new cases of cancer were diagnosed worldwide in 2008, an increase of a fifth in less than a decade (WHO 2011). Out of these 12 million at least 2.8 million are connected to obesity (Yach 2010).
Although the damaging effects of smoking have been known for a long time and the regulatory procedures of taxation, age restrictions and bans on advertising are in place, the research suggests that despite this deaths connected with smoking (primary and second-hand smoking combined) will double from 3.4 million to 6.8 by 2030 in the developing countries (NCD Alliance, 2011). As western countries governments make it harder for tobacco companies to expand their markets in the developed countries, the developing countries will take a leading place in tobacco consumption as the regulations are weaker there. China is a vivid example of the booming tobacco industry and a very high level of smokers, with more than 320 million smokers and approximately 35% of the world’s tobacco production (FAO, 2004; Global Adult Tobacco Survey - China Section, 2010). Tobacco accounts for 30% of cancers globally, and the annual economic burden of tobacco-related illnesses exceeds total annual health expenditures in low- and middle-income countries (American Cancer Society & World Lung Foundation, 2009). Another characteristic of tobacco consumption in the developing countries is choosing to purchase cigarettes instead of other family or personal needs such as food, medication and education. This also contributes to slowing down development.
Like smoking alcohol is also connected with cancer and many types of cardiovascular disease (Boffetta & Hashibe, 2006). Cardiovascular disease killed 17.1 million people in 2004 – 29% of all global deaths. 82% of deaths from CVD take place in low- and middle-income countries, and many of these deaths will be premature.33 For example, in South Africa 41% of deaths from CVD will be among those aged 34–65 (people of working age), compared to just 12% in the United States.34 The main difficulty in measuring the economic impact of NCDs is the lack of research compared to the abundant data concerning health risk of NCDs. Nevertheless, scholars and economists raise the question of substantial macroeconomic impacts on labour supply, capital accumulation and GDP worldwide with the consequences most severe in developing countries (Abegunde & Stanciole, 2006).
The massive global toll of NCD not only poses a threat to global health, but increases poverty, slows down international development and economic growth. To better understand how NCDs have become a world dominant death cause so quickly it is paramount to analyse risk factors that lead to non-communicable diseases. There are two types of factors responsible: modifiable and non-modifiable factors. Non-modifiable factors cannot be altered or changed by neither the environment nor an individual and they include genetic predisposition, age and sex. Modifiable risk factors mean that they could be changed in order to improve general heath and lessen the risk of diseases. WHO typically refers to four major ones for NCDs: poor diet, physical inactivity, tobacco use, and harmful alcohol use (WHO, 2011a).
Chand (2012) argues that the projected economic losses due to NCDs will reach a staggering $47 trillion. He identifies globalisation as one of the main triggers of increased consumption of unhealthy foods, alcohol and tobacco. From an economic point of view tackling NCDs is vital for future economy. Substantial funds are needed to cover the medical costs of treating NCDs and this puts extra pressure on health systems and governments around the world. However, investing money in treating and preventing NCDs can be financially viable - for every dollar invested in NCDs, one can expect three dollars in return (Beaglehole 2011). For example, the World Bank reviewed the economic benefit of reducing cardiovascular disease alone by 1% per year from 2010 to 2040. In China, this could generate more than $10.7 trillion, equivalent to 68% of China’s real GDP in 2010 (World Bank 2011). Non-communicable diseases are likely to diminish family earnings and the capacity to support and educate children. People affected by NCDs are also more likely to take a sick leave more often, quit their jobs or retire early. This paints a grim picture of how health problems affect the global economy.
The root of this phenomenon lies in the changes took place in the 20th century – firstly, through industrialisation and migration to big cities at a national level followed by environmental changes and technological development contributed to a drop in physical activity. Automated production of food made it more affordable and since the supply is more than demand the obesity rates stared to grow. Although the changes were introduced from the outside, when dealing with the consequences the policy makers highlight the importance of individual choice and responsibility. The ground for that is that well-informed people will make sensible choice about what they consume and how much they choose to exercise even in the face of heavy marketing and promotion.
Raising awareness globally takes time and a soft approach of non-interference could work in the long term but to slow down the epidemic of NCDs it is necessary to regulate the market to channel and influence consumer behaviour towards restrained and less harmful use. It is more complicated to regulate people’s diet and physical activity as food is vital for a human to survive and compulsory exercise is not implemented in policy-making. However, we could use the history of alcohol and tobacco regulation which has proven to be successful. At the same time there is a risk than by regulation certain products consumer could switch to cheaper and more dangerous equivalents.
While it is clear that the UN and the WHO make NCDs a global health priority, the same is happening in the economic field. In 2009 the World Economic Forum carried out a survey which identified NCDs as a potential threat to a global economic growth placing them among other severe risks such as underinvestment in infrastructure, fiscal crises, and unemployment. The report analyses not only the possible consequences but as well takes into account a complicated context of global health spending, use of public funds and concerns about economic growth (Bloom et al. 2011). We have established that NCDs visibly affect global health now and the projections suggest that the situation will worsen in the future but the economy will be influenced as well through an economic impact on households, industries and societies, both via the consumption of health services and via losses in income, productivity and capital formation due to high mortality and disability.
Both in the developed and the developing countries the costs of treatment of NCDs combined with the loss of productivity burden governments and businesses: for example, in China and Brazil staggering $3 billion and $72 billion are spent yearly (IOM 2010). Such great amounts of money go into coping with current rise of NCDs, so economists should consider investing in prevention programs as such expenses could diminish a country’s productivity in the future. Another reason to act on NCDs quickly is the growth of the world population together with global ageing. With the fertility rates falling and the expectancy of life rising more medical and social care will be needed. This suggests that the acceleration of NCDs can be expected as the elderly are the most prone to non-communicable diseases.
Although the problem of global ageing is more acute in the developed countries at the moment, if globalisation is about to go on at the same rate the developing countries will be facing the same problem. The data supports the fact that out of a total world expenditure on health of US$ 5.1 trillion in 2009, more than a half, US$ 4.4 trillion, occurred in the developed countries (Chand 2012: 37).
To sum up the economic impact of NCDs we will focus on the three aspects most likely to be influenced by these diseases. Firstly, although NCDs are more common in the elderly lost productivity is an important issue especially in the developing countries. Deaths are a result of long term illnesses which take their toll not only on the income earner but their families as well. Secondly, national income will suffer from economic losses which are estimated at $47 trillion by 2030. Thirdly, previous factors will accelerate household poverty are unable to work due to illnesses and cannot get enough governmental support on medical care. Spending on medical costs will increase while earning capability decreases.
Chand (2012) argues that a combination of personal choices coupled with governmental policies can reverse the negative effects of NCDs. A healthy global population is crucial to supporting progress across the three pillars of sustainable development economic growth, social equity, and environmental protection. It is important to bear in mind that securing and promoting good health for all depends on the integration of NCD prevention and control into sustainable development policies and programs. By doing so, governments will mitigate the negative impacts of unsustainable development practices and reverse the trajectory of the NCD epidemic.
Non-communicable diseases are indeed a pandemic of the 21st century. Cancer, diabetes, chronic respiratory diseases and cardiovascular diseases have already taken the lead among other illnesses and are the leading cause of death worldwide. While infectious diseases and AIDS still present a great threat to the global health, NCDs are to a certain extent more difficult to trace and cure as the illness does not appear after a single act of smoking, drinking alcohol or indulging in fast food. Although such risk factors as poor diet, lack of physical activity, tobacco and alcohol use are known and could be easily preventable by people themselves NCDs have become both health and economic concern.
Tackling NCDs is not easy as personal choices are often influenced by external factors. These factors stem out of the speeding globalisation and urbanisation, aggressive marketing and taking advantage of the developing countries markets. Therefore, the international response should be multifaceted. The Political Declaration (UN General Assembly 2011) signed by the UN members in 2011 offers the following steps in order to cap the spread of NCDs:
Responding to the challenge: Taking a whole-of-government and a whole-of-society effort. NCDs is a battle which should not be fought from one side only, it requires cooperation, leadership and multi-sectoral effort. While cooperation between citizens and governments is important, multinational organisations sometimes have a clash of interest with public health (tobacco and alcohol industries). At the same time treating NCDs should be proactive not reactive only dealing with consequences.
Reduce risk factors and create health-promoting environments: The importance of full implementation of the existing programs and policies cannot be underestimated. Thus the Framework Convention on Tobacco Control, the WHO Global Strategy on Diet, Physical Activity and Health, and the WHO Global Strategy to Reduce the Harmful Use of Alcohol should be implemented quicker to achieve better results. The section also emphasises a need of promoting healthy foods (e.g. working towards reformulating products, reducing salt and eliminating industrially produced transfats), promote and support breastfeeding, and increase access to cancer screening and other medicines to prevent/control NCDs.
Strengthen national policies and health systems: This calls for the establishment and strengthening of national policies and plans on NCDs by 2013, according to national circumstances, including risk factors, surveillance, treatment and care. It notes the need to take gender-based approaches and to recognise the needs of indigenous people, as well as the importance of universal coverage for poor populations. It also encourages networks to develop new medicines and technologies, particularly learning from HIV/AIDS.
International cooperation, including collaborative partnerships: Exchange of best practice in health promotion, regulation, technology, medicines etc. is highlighted, and the need for the UN, development banks and other key organisations to work together. It also encourages non-health actors (including, where appropriate, the private sector) to form collaborative partnerships to reduce the risk factors.
Research and development: Promotion of investment in research on prevention and control of NCDs, including incentivising innovation and using information technology.
Monitoring and evaluation: Strengthening surveillance at country level is recommended – and it specifically calls on the WHO in collaboration with member states and others, to ‘prepare recommendations for a set of voluntary global targets for the prevention and control of NCDs, before the end of 2012’ and to consider developing national targets and indicators.
Follow-up: The Secretary General is requested to submit to the General Assembly (by the end of 2012) options for strengthening action through effective partnership, and is also requested to present a report on achievements towards the fulfilment of the Political Declaration, in preparation for a comprehensive review in 2014 of progress made, including impact on achievement of the MDGs.