PERSPECTIVES

Ethical tensions in dealing with noncommunicable diseases globally

Sridhar Venkatapuram^I; Martin McKee^I; David Stuckler^II,*

^ILondon School of Hygiene and Tropical Medicine, London, England
^IIDepartment of Sociology, University of Cambridge, Free School Lane, Cambridge, CB2 3RQ, England

Noncommunicable diseases pose an increasingly high burden of disease that threatens economic and social development, yet cost-effective health interventions exist. World leaders recognized the compelling case for action with the declaration at the United Nations high-level meeting on noncommunicable diseases in September 2011. ^{1 , 2} Since that meeting, the World Health Organization (WHO) has been developing a Global Monitoring Framework and the United Nations Secretary-General is preparing to report to the 67th session of the General Assembly in September 2012 on ways to tackle noncommunicable diseases across different sectors.

This paper aims to inform these debates by reviewing the declarations that resulted from WHO regional meetings held in preparation for last September's high-level meeting (Table 1). We identified four "ethical tensions" that must be resolved. These tensions are not exhaustive or mutually exclusive but provide a framework for debate.

Human rights approaches

Effective action on noncommunicable diseases involves addressing multiple human rights, such as the right to information to make informed choices about diet and activity (e.g. food labels that people can understand), the right to bodily integrity (e.g. freedom from exposure to second-hand smoke); and the right to health (including access to essential medicines). These human rights may conflict with corporate rights, such as the right of pharmaceutical companies to exploit patents or express freedom of speech (through marketing).

Human rights language featured much more prominently in United Nations declarations on the human immunodeficiency virus (HIV) than those on noncommunicable disease. The European Region was the only one to argue that "Member states need to... respond effectively and equitably to the health-care needs of people with NCDs [noncommunicable diseases] as part of the fundamental human rights of every human being". ³ There has been no reference to essential medicines in any of the regional declarations, despite evidence of the benefits of cheap generic drugs, such as the polypill.

Social determinants

Political leaders face difficult decisions about where to invest resources along the causal chain of disease. They must care for those already ill but also tackle the underlying causes of the diseases. Five of the seven regional documents mention the importance of action on social determinants. For example, the Brazzaville declaration noted how "... risk factors and the systems put in place to deal with the conditions in which people live are shaped by political, social, behavioural, environmental and economic determinants". ⁴ Others did not use the term "social determinants" but they were considered implicitly. ⁵

Funding

Governments must balance the needs of their own citizens with their obligations to provide aid to other countries. There is a glaring global inequality in the burden of noncommunicable diseases and in the domestic resources available to address them. This raises the basic question of the obligations of rich countries to help poor countries to deal with these diseases. It is difficult to draw on self-interest arguments, such as threats to national security, as has been posed for tackling HIV/AIDS. And, while many health interventions are considered for the global public good, this argument may not be sufficient. There is currently little appetite in rich countries for committing more aid funding. Donors face the dilemma of whether to re-allocate existing funds targeting infectious diseases to noncommunicable diseases. Although these diseases may benefit from a shift from disease-specific programmes to one focused on health systems strengthening, it is difficult to see where resource-poor countries will find funding specifically for action on noncommunicable diseases.

All of the regional declarations (except the one made in Nadi which did not address resource issues) ⁶ argued that noncommunicable diseases should be included in international development goals, although they differed in how this might be supported financially. Declarations made in Oslo and Jakarta, for example, emphasized that further domestic funding would be needed. ^{3 , 5} One possibility is to leverage existing resources to address the interactions between infectious and non-infectious diseases, such as the role of tobacco as a risk factor of both tuberculosis and noncommunicable diseases.

Which diseases?

All governments must set priorities for action, such as whether to focus on interventions for those people in most need, those who would benefit most or on actions that would benefit the most people. The high-level meeting initially prioritized four diseases (cardiovascular disease, cancer, chronic lung diseases and diabetes) with high mortality burdens and four risk factors (tobacco use, poor diet, harmful use of alcohol and physical inactivity). However, the political declaration that was signed at that meeting mentioned high-disability mental and neurological disorders (as were included in the Oslo, Mexico City and Brazzaville declarations), as well as additional risk factors including exposure to smoke from indoor-cooking stoves.

The case for focusing on four diseases is that they have common causes and there are wider benefits achieved by tackling them all. Yet mental illness is also a common accompaniment of physical disease. Strengthening health systems to provide chronic, long-term care should improve mental health care, and action on mental health risk factors, such as harmful use of alcohol, will also help.

The political declaration is a great step forward but beneath lie ethical dilemmas, visible in the tensions and differences between the regional declarations on noncommunicable diseases. We must first address these tensions if we are to move from high-level commitments to effective action.

Acknowledgements

The authors are grateful to Gauden Galea for developing the ideas in this paper and for helpful comments on various drafts.

References

1. Alwan AD, Galea G, Stuckler D. Development at risk: addressing noncommunicable diseases at the United Nations high-level meeting. Bull World Health Organ 2011;89:546-546A. doi: 10.2471/BLT.11.091074 PMID: 21836748        

2. Alleyne G, Stuckler D, Alwan A. The hope and the promise of the UN Resolution on non-communicable diseases. Global Health 2010;6:15. doi: 10.1186/1744-8603-6-15 PMID: 20828416        

3. Addressing noncommunicable diseases: major challenges to sustainable development in the 21st century; Oslo, Norway. Copenhagen: World Health Organization Regional Office for Europe; 2010.         

4. Brazzaville Declaration on noncommunicable disease prevention and control in the WHO African Region. Brazzaville: World Health Organization Regional Office for Africa; 2011.         

5. Jakarta Call for Action on Noncommunicable Diseases. New Delhi: World Health Organization Regional Office for South-East Asia; 2011.         

6. Nadi statement on the NCD crisis in Pacific Island Countries and Areas (PICs), Nadi, Fiji. Manila: World Health Organization Regional Office for the Western Pacific; 2011.         

Submitted: 16 August 2011
Revised version received: 16 November 2011
Accepted: 29 November 2011
Published online: 3 February 2012
Competing interests: None declared.

* Correspondence to David Stuckler (e-mail: ds450@cam.ac.uk).