Special IssueRethinking global health challenges: Towards a ‘global compact’ for reducing the burden of chronic disease
Introduction
One of the most important challenges in global health is how to address the epidemic of chronic, non-communicable disease, despite the unfinished agenda of perinatal health and communicable disease, as reflected in the Millennium Development Goals (MDGs). The MDGs contain three specific health goals: reduce child mortality; improve maternal health; and combat human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), malaria and other diseases.1 Together, these account for 32% of global mortality.2
By 2001, however, non-communicable diseases accounted for 59% of global mortality; nearly 54% of deaths in low- and middle-income countries, and 87% of deaths in high-income countries.3 Cardiovascular disease (CVD) is the leading cause of death in all regions except sub-Saharan Africa. It accounts for over one in four deaths in high-income countries, and over one in five deaths in low- and middle-income countries where it causes nearly twice as many deaths as tuberculosis, HIV/AIDS and malaria combined.3 CVD mortality rates in working-age populations are substantially higher in emerging economies, undermining productivity and the benefits of the lower dependency rates enjoyed by countries with younger populations.4 Worldwide, there are more than 1.1 billion adults who are overweight, and 312 million of these are obese.5 Diabetes is expected to double from 171 million to 366 million cases over the period 2000–2030. Developing countries will shoulder the burden of this problem (especially India, China, Southeast Asia and the Western Pacific), with incidence peaking in those aged 45–64 years.6
The transition towards chronic diseases reflects many factors including the ageing of the population (due to declining fertility rates and improved infant survival), the relative success of efforts to control communicable diseases, and the globalization of risk factors for chronic diseases. Driven by income growth, direct foreign investment in supermarkets and heavily marketed, processed foods, there has been a ‘nutrition transition’ towards diets richer in fats, sugar and salt.7, 8, 9 Other factors include greater participation of women in the workforce, urbanization and the accompanying trend towards more sedentary lifestyles, and the global marketing of tobacco. Chronic diseases are not confined to affluent countries, nor do they only affect those who have consciously chosen unhealthy lifestyles.10, 11 Due to rising rates of cancer, CVD and chronic obstructive pulmonary disease, deaths from chronic disease are expected to increase by 17% over the period 2006–2015, accounting for nearly 70% of global deaths by 2030.12 For all these reasons, global health advocates have argued that donor governments and global agencies with a stake in health should direct a greater share of resources and policy attention to the looming ‘lifestyle epidemics’ of the 21st Century, particularly CVD, cancer, diabetes and tobacco-related diseases.4, 10, 11, 13, 14, 15, 16, 17, 18, 19
This paper reviews current policy initiatives for global action on chronic diseases, with a particular focus on the role of obesity and nutrition. Chronic diseases call for policies and programmes across a variety of sectors and this necessarily implies a degree of complexity at national level. There is growing interest in the role that the law can play in implementing national policies on chronic disease prevention, including the prevention of population weight gain.20, 21, 22, 23, 24, 25, 26 In addition, however, the looming burden and shared challenge of chronic disease in developing countries, together with the transnational factors contributing to their spread, call for a ‘global response’. But what, exactly, does this mean?
At global level, since no single government, international institution, foundation or other funder has the resources, expertise and influence to write the script for a comprehensive national response to chronic disease in low- and middle-income countries, the cooperative provision of technical and financial assistance is required. The management of global health issues at transnational level is no longer the sole preserve of nation states, or international agencies controlled by nation states. Private foundations and public–private partnerships wield significant economic power, and ‘moral networks’ embracing a wide range of health issues have leveraged the political influence of non-governmental organizations (NGOs) and civil society generally.27, 28, 29 New political groupings, such as the G8, and World Economic Forum, are also assuming major significance in placing global health issues on the agenda.30, 31 Fidler has coined the term ‘open source anarchy’ to describe the challenges to governance in this constantly evolving and non-state-centric environment.32, 33 According to Fidler, the global health environment is one of ‘unstructured plurality’; a ‘diversity of actors, interests, norms, processes, initiatives, and funding streams’.32
This paper provides one way of conceptualizing a response to these challenges. It highlights how: (i) international legal norms; (ii) economic processes; and (iii) collective political will formalized through governance structures and partnerships between governments, global agencies, private funders and civil society groups can function as three, concurrent pathways for advancing policies and programmes on chronic disease. The paper evaluates the World Health Organization's (WHO) initiatives on chronic disease in terms of these pathways, and proposes a global compact on chronic disease as a possible structure for advancing concrete goals for reductions in mortality rates from chronic disease.
Section snippets
Chronic disease and the challenge of global health governance
A feature of global challenges of any sort is that there is often no suitable agency, organization or government with the resources, technical capacity, credibility, and legal and political mandate to act as a catalyst for global action, liaising between stakeholders and helping to coordinate a truly effective global response. This challenge is especially stark in the case of chronic diseases. At transnational level, actions are required by global agencies, governments, transnational
WHO and the World Bank
Collective action at global level is required if countries are to respond successfully to transnational factors influencing rates of smoking, patterns of diet and nutrition, and physical activity.13 Hitherto, the global framework for action on chronic diseases has been largely embodied in two WHO initiatives: the FCTC41 and the Global Strategy on Diet, Physical Activity and Health (GSDPAH).34 Further impetus has come from several influential WHO reports.58, 59
The tobacco initiative is
Future possibilities for global action on chronic disease
As suggested by the GSDPAH and WHO's action plan for non-communicable disease, a comprehensive response to chronic disease at national level is necessarily complex. It includes capacity building, strengthening the primary healthcare system, policies addressing the behavioural, socio-economic and environmental determinants of disease in a variety of sectors and settings, surveillance and monitoring of the burden of disease, the promotion of research capacity, and attention to health inequalities.
Conclusion
Fidler argues that efforts to develop ‘new architecture’ for coordinating global health efforts fail to understand that global health is no longer ‘the house that WHO built’, but has evolved to become ‘an integrated global public good’ with strategic relevance to multiple areas of governance.32 According to Fidler, in a global environment of ‘unstructured plurality’, both states and non-state actors may resist governance solutions that aim to centralize and systematize the multiplicity of
Ethical approval
None sought.
Funding
Australian Research Council (ARC) Discovery Project Grant DP0667271.
Competing interests
None declared.
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