It has been argued by Ventkatapuramet al.(2012) that there are four key tensions that must be resolved in the development and implementation of global strategy on NCDs, including; 1) the tension between human rights and corporate rights, 2) tensions regarding where to invest in health along the ‘causal chain’ (from social determinants to treatment services), 3) tensions in governments funding programs for their own countries versus development assistance for developing countries, and 4) which diseases to prioritise (mental health was mentioned in the Political Declaration on NCDs but subsequently dropped as a focus in that plan).
Read the article by Venkatapuram and have a look at the global NCD Strategy: United Nations General Assembly. A/66/L.1.Political declaration of the High-level meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, 16th September 2011
As you consider these strategies, using a critical approach, report:
What do you consider to be the main tensions in supporting NCD strategy within your country (e.g. including those involving local determinants)? You may choose to focus on one NCD to illustrate your points.
What might be some other tensions in working across sectors for global NCD strategy?
The four major chronic non-communicable diseases (NCDs) are cardiovascular disease, type 2 diabetes, cancers and chronic lung disease.
Hancock (2013) reports that they account for over 60% of deaths in the world, double the number of those from all infectious diseases (including HIV/AIDS, TB and malaria), maternal and perinatal conditions, and nutritional deficiencies combined.
“19 million of the 36 million deaths from NCDs each year occur in those aged under 60, … and 80% of the total deaths from NCDs occur in low- and middle-income countries. Up to 80% of premature deaths from these diseases could be prevented by tackling just three risk factors: poor diet (including the harmful use of alcohol), tobacco use and lack of physical activity.”
“Mental illness also falls into the category of NCDs, and is the cause of significant disability.”
The editorial of New Scientist (30 Nov 2013) reports
“Evidence is growing that Alzheimer’s could actually be a late stage of type 2 diabetes” 
WHO (2013) (2014) notes
“Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of type 2 diabetes.”
“The number of people living with dementia worldwide is currently estimated at 35.6 million. This number will double by 2030 and more than triple by 2050.”
Ventkatapuram et al.(2012) note four key tensions to resolve to develop and implement global strategies about NCDs:
· Human rights versus corporate rights
· Where to invest in health along the ‘causal chain’ from social determinants to treatment services)
· Governments’ funding programs for their own countries versus development assistance for developing countries
· Which diseases to prioritise
The UN General Assembly (16 September 2011) adopted the political declaration of high level meeting on the prevention and control of non-communicable diseases. NCD’s are one of the major challenges, burdens and threats to development in the twenty first century throughout the world.
Physical activity, healthy lifestyles, diet, health and alcohol are critically important. The main ncd’s are cvd, cancer, crd, and diabetes. There are a range of other ncds including maternal and perinatal conditions, nutritional deficiencies, mental and neurological conditions like Alzheimers, renal, oral and eye diseases.
Common risk factors are tobacco, alcohol, unhealthy diets, lack of physical activity, poverty, uneven distribution of wealth, lack of education, rapid urbanization and population ageing. There is a disproportionate burden of care giving on women.
There are vicious cycles – low birth weight because of malnutrition causes a predisposition to obesity, high blood pressure, heart disease and diabetes, and inefficient heating and cooking stoves cause smoke, cancers, crd’s and widespread air pollution.
Concentrating on two factors, healthy diets and physical activity has been shown to have significant effects on reducing body mass index and enabling general health and fitness, and therefore preventing diabetes and its complications including Alzheimer’s.
The association between excessive weight gain, central adiposity and the development of type 2 diabetes is convincing. The association has been repeatedly demonstrated in longitudinal studies in different populations, with a striking gradient of risk apparent with increasing levels of BMI, adult weight gain, waist circumference or waist-to-hip ratio. Indeed waist circumference or waist-to-hip ratio (reflecting abdominal or visceral adiposity) are more powerful determinants of subsequent risk of type 2 diabetes than BMI (16–20).
WHO (2003) recommends a life-cycle approach, starting with breast feeding. LDL cholesterol and glucose intolerance are critical factors in adolescent high blood pressure.
“The presence and tracking of high blood pressure in children and adolescents occurs against a background of unhealthy lifestyles, including excessive intakes of total and saturated fats, cholesterol and salt, inadequate intakes of potassium, and reduced physical activity, often accompanied by high levels of television viewing (10). In adolescents, habitual alcohol and tobacco use contributes to raised blood pressure”.
The term “metabolic syndrome x” has been used.
The English NHS has a programme Change4Life. It recommends cutting back on saturated fat, avoiding salt, 5 a day (Canada has 10), watching out for sugar and doing stuff.
Jamie Oliver has been very important.
“Imagine a world where children were fed tasty and nutritious, real food at school from the age of 4 to 18. A world where every child was educated about how amazing food is, where it comes from, how it affects the body and how it can save their lives”.
Sustrans Safe Routes to School notes:
We work with hundreds of schools throughout the UK each year to encourage pupils to be more active, enabling thousands of children to travel actively and safely.
We have more than 120 expert officers working intensively in over 1,400 schools across the UK and we are supporting several hundred more schools. Our officers have an enormous impact in the first year of working with a school, typically achieving:
· Double the number of children cycling to school everyday;
· Over a quarter of children regularly cycling to school; and
· Fewer cars on the school run.
Ventkatapuram’s four tensions are possibly misleading because they are too summarised.
Human Rights and Corporate Rights
With regard to human rights versus corporate rights, this is probably simplistic. When Volvo invented the seat belt in 1959 they released the idea on an open patent. Companies are creatures of habit and are institutionalised. They will attempt to exploit their market niches. They do follow law though – lead is no longer available in petrol for example. Government has always made laws about how people may trade- this may be the core reason government was invented, around coinage, markets and weights and measures – and thus what people attempt to sell or control is really a matter of government intervention. New laws and implementation of existing laws are required around alcohol, tobacco, salt and fats and related matters. Governments just need to get on with implementing them, as they have with smoking in public buildings. There will be problems. Monopolies and similar behaviours like fraud are commonplace.
Up to the 1950’s Los Angeles had an excellent electric powered transit system. Oil, car and rubber interests destroyed it.
“The General Motors streetcar conspiracy (also known as the Great American streetcar scandal) refers to allegations and convictions in relation to a program by General Motors (GM) and other companies who purchased and then dismantled streetcar and electric train systems in many American cities.
Between 1936 and 1950, National City Lines and Pacific City Lines—with investment from GM, Firestone Tire, Standard Oil of California, Phillips Petroleum, Mack Trucks, and the Federal Engineering Corporation—bought over 100 electric surface-traction systems in 45 cities including Baltimore, Newark, Los Angeles, New York City, Oakland and San Diego and converted them into bus operation. Several of the companies involved were convicted in 1949 of conspiracy to monopolize interstate commerce but were acquitted of conspiring to monopolize the ownership of these companies.”
Where to invest in health
Where to invest is also easily resolved, at the critical points in the life-cycle, and in ways that are preventive like healthy cities:
Basic features include community participation and empowerment, intersectoral partnerships, and participant equity.
A Healthy City aims to:
· to create a health-supportive environment
· to achieve a good quality of life
· to provide basic sanitation & hygiene needs
· to supply access to health care
Being a Healthy City depends not on current health infrastructure, rather upon, a commitment to improve a city’s environs and a willingness to forge the necessary connections in political, economic, and social arenas.
Berlin has used the phrase “ecological orientation”.
Internal and external governmental funding is also easily resolved by creating real partnerships whereby people learn from various systems and transfer skills knowledge and experience between them. This is a symptom of silo thinking.
Which Diseases to prioritise?
Diseases are symptoms of something faulty. It is not necessarily an issue of which diseases to prioritise but that which causes those diseases should be prioritised. If Alzheimer’s is caused by type 2 Diabetes and Type 2 Diabetes is caused by …
This is whole system thinking.
As one of the astronauts commented, there are no boundaries from space.
What are required are very careful audits of the histories of individuals, families and communities, where they are now in their lives and the issues they are facing, and discussion and agreement of where they wish to be. Diseases will be part of this, but experience in primary health care has shown diseases are often not the most important perceived issues.
“In our experience, no other health program in the world has an equivalent record of long-term and innovative program design; improving health; promoting new methods and technology in other places which continues to be relevant as new community priorities emerge; empowers the community, women and marginalized groups; tackles the root causes of ill-health; collaborates with other individuals and organizations; and provides field training in practical aspects of program implementation for people from around the world.”
 Hancock C (2013) Non Communicable Diseases in the UK C3 Collaborating for Health London
New Scientist 30 Nov 2013 Reed Business Information Ltd London
 http://www.who.int/mediacentre/factsheets/fs312/en/ WHO Geneva 2013
 http://www.who.int/mental_health/publications/dementia_report_2012/en/ WHO Geneva 2012
Bull World Health Organ 2012;90:241–242 | doi:10.2471/BLT.11.094789
UN 16 September 2011
Diet, nutrition and the prevention of chronic diseases Report of the joint WHO/FAO expert consultation
WHO Technical Report Series, No. 916 (TRS 916)
Perri 6. (1997) Demos London
Leading Change: A Guide to Whole Systems Working
The Policy Press, 2003