From the President: Reflections from Geneva - NCD at WHA

The sunshine was glorious. The setting was spectacular. The stakes were high. We were in Geneva for the 64th meeting of the World Health Assembly (WHA). The talk of this year’s WHA was non-communicable disease (NCD), but more on that later.

Each May, the WHA brings together the 193 member states that comprise the World Health Organization (WHO). Led by their health ministers, the WHA delegates discuss current issues, adopt policies, and elect the leadership of WHO. The past several years have been difficult financially for the donor nations and thus for WHO, which had a budget shortfall of USD 300 million, in 2010. WHO has reduced its staff of 2400, by 300 people. This year, the WHA trimmed the WHO budget request by 20%, down to USD 3.98 billion over the next 2 years. The United States is the largest annual donor, at USD 250 million; followed by the Bill & Melinda Gates Foundation, at USD 219 million.

The WHA plays out over nine days, but the first two are when most of the non-governmental organizations (NGOs) meet with each other and WHO staff. Michael Kidd, WONCA President-Elect; Iona Heath, WONCA Liaison to WHO; and I represented WONCA at this year’s WHA. Michael had the most experience at WHA, so Iona and I spent several days chasing him up and down hills and stairs, winding around buildings, and climbing some more hills and stairs. We hustled between the Palais des Nations, where the General Assembly met; WHO headquarters, where we conferred with staff; and area hotels, where we heard presentations by, and networked at receptions with, the leaders of the many other NGOs attending the WHA. Our two days in Geneva were very full, with non-stop sessions between nine in the morning and ten at night.

Profs Iona Heath, Richard Roberts at the WHA

On our second day, there were two guest speakers. Sheikh Hasina, Prime Minister of Bangladesh, spoke of her vision of a “Digital Bangladesh” by 2021. She plans to lift her nation to middle income country status through investment in education and health programs. Bill Gates, co-chair of the Bill & Melinda Gates Foundation, described his commitment to vaccines.

This year, there was a curious disconnect between the official debate and less formal discussions away from the floor of the Assembly. Numerous delegates spoke out on the floor and in committees of the continuing need to strengthen health systems and to advance integration of care through primary care. Yet, the buzz in the Serpentine coffee shop of the Palais and the NGO-sponsored panel presentations at the hotel receptions focused on NCD.

The growing importance of NCD is irrefutable. NCDs have surpassed infectious disease as the leading cause of mortality. Four NCDs – cancer, cardiovascular disease, chronic respiratory disease, and diabetes – now account for about 60% of deaths worldwide. The relative burden on poor countries is even greater, with 80% of NCD deaths occurring in developing or transitional economies. Tobacco use, unhealthy diet, physical inactivity, and the harmful use of alcohol are the four behaviors that drive these four important chronic conditions. These four diseases and four behaviors have prompted a “4 by 4” campaign.

The disease-focused NGOs hope that “4 by 4” will move the global community to action on NCD, much as “3 by 5” propelled HIV-AIDS efforts earlier this decade (3 million people in developing countries started on anti-retroviral medications by 2005). In 2001, HIV-AIDS was the theme of the first and thus far only United Nations (UN) Summit on a health topic. The UN has agreed to convene a second health Summit, which will focus on NCDs, and which is scheduled for 19 September 2011, in New York City. A UN Summit on a health issue may seem like a good thing, but it raises several important concerns that the WONCA team emphasized in Geneva.

View of the World Health Assembly meeting in Geneva.

While cancer, cardiovascular disease, chronic respiratory disease, and diabetes are important, there are many other chronic conditions that also cause considerable morbidity and mortality. Even more worrisome is that the UN Summit on NCDs does not plan to include the perspectives of primary care or mental health. The NCD community argues that to include more than the four specified conditions will dilute their message and confuse their target audience – UN leaders. These are the same leaders we ask to deal with issues like the global economy, armed conflict, and poverty.

As I made my way home from Geneva, I reflected on our busy two days. I was impressed by the good will and good intentions of the many leaders of NGOs, WHO staff, and WHA delegates that we met. It was heartening to hear their expressed support of primary care. Yet, it was distressing to watch that support wither in the face of the narrow agenda of the NCD community and their industry supporters.

I left worried that primary care’s increased visibility over the past few years will be overshadowed again by the granular focus on single diseases. I thought back to the first UN Summit on a health issue. That Summit on HIV-AIDS raised global awareness and resulted eventually in the Global Fund. The resulting dramatic rise in AIDS funding however, tempted some local health systems and professionals to concentrate exclusively on HIV-AIDS to the detriment of the overall health of the greater community. It was this unintended outcome that stimulated the creation of the “15 by 2015” initiative.

This international effort asks donors and funders by 2015 to dedicate at least 15% of their funding for targeted diseases (vertical programs) to the support of the primary care infrastructure (horizontal programs).
We will continue to press NGO leaders, WHO and UN staff, and national ministries to include primary care and mental health in their planning for and deliberations at the UN Summit in September. It seems that the international health community now knows who we are, but needs to understand that their words of support mean less than our opportunity to speak for ourselves. We have more work to do. Your advice and support are most appreciated.

Professor Richard Roberts