WARNING: Health’s NCD label set for name change? And why Pacific health leaders need to be ready
Pacific health ministers will converge on the Cook Islands from 28 to 30 August for the biennial Health Ministerial, the 12th in the series that started in Fiji, 1995.
The ministerial-level talk-fest is invaluable. A space where ministers develop regional consensus and set future health directions based on the “Healthy Islands” concept proposed at the first biennial in Fiji, and adopted two years later in the Cook Islands.
The ‘Healthy Islands’ concept’s principal vision is about carving out an integrated regional response to rapidly changing social and economic conditions, both local and global, affecting the quality of life and health in Pacific island countries and areas.
The biennial meetings therefore is a regional platform where ‘Health Ministers’ can sign off on key actions to strategically respond and protect the region’s wellbeing.
More importantly, what it spotlights is the critical importance of ‘health leaders and officials’; and their commitment to vigilance. That in order for the ‘Healthy Islands’ concept to work, and for Ministers’ signatures to be effective in driving sound and integrated policies, health leaders and officials need to be operating at the top of their game. That they are providing effective up-to-date policy-relevant briefings on key global developments; and be able to confidently point out where to position the region to ensure maximum coverage and resources are engineered towards priority health concerns of the Pacific.
If they don’t, or fall asleep at the wheel, and a revolutionary shift is taking place then the Pacific could end up heading down the wrong path of a priority health issue, and risk being left behind as the world heads off in a different or opposite direction.
A costly error, both in lives, efforts and resources to redress something that can be averted at the source if health leaders remain vigilant to the nuances of trending developments. Vigilance is now even more critical with the recent ‘relabeling’ of the sector from “international health” to “global health” demonstrating that even a minute shift, such as a name change, can galvanize the re-conceptualization of an entire field.
At the moment, one such global shift, also a name change, could be taking place in the disease group currently named Non-Communicable Diseases (NCD), the leading cause of deaths worldwide. If it happens, there will be some major implications for the Pacific.
NCD is a Pacific big-ticket health item as it mirrors NCDs global impact as the Number-1 cause of deaths worldwide. The disease group has consistently been one of the “three major themes” the series of Pacific biennial meetings have focused on in the recent past:
- The predominant and growing burden of non-communicable diseases (NCDs);
- The lingering burden of infectious diseases and the dangers of their re-emergence; and
- The need to support health systems so that they can cope with the double burden of communicable and non-communicable diseases.
Yet despite its Number-1 killer status, NCDs receive the lowest overseas development assistance per disability-adjusted life-year, and even the most cost-effective NCD interventions are severely underfunded compared with their infectious disease counterparts. What’s more, NCDs are under-represented in developing countries’ national health plans, undermining progress towards reaching universal health coverage and improvement of human capital.
Which is why there is an ongoing debate, at the global level, on how best to address this lack of action. And recently, the majority in the health sector is trending towards the name, NCD itself, as the main cause of the problem.
They say that its long-winded “anti-definition” name is hampering and limiting actions to cure the conditions currently labeled as NCDs. A problem set to remain top of the list for years to come with NCDs expected to cost the global economy US$47 trillion over the next two decades, and continue to push millions of people into poverty.
The latest ‘name-change’ call comes from a survey and online discussions recently published by the Lancet in July 2017. It also included responses to an initial article that demonstrated “no-one has a very good grasp of what NCDs actually are in the first place.”
In fact, the Lancet article states one of the main limitations of the current name and why it should be replaced is that “many NCDs are in fact ‘communicable’, and the current anti-definition provides no information about what unites these conditions.”
It further adds that “the current list of NCDs describes a ragtag group of leftovers that do not satisfy Koch’s postulates (Berliner Klinische Wochenschrift. 1882; 15: 221–230) nor fit neatly into other categories.”
For the layman, NCDs are usually known by the “big four” – cardiovascular disease, cancer, chronic respiratory disease, and Type-2 diabetes. For those in the health sector, NCDs also include congenital conditions (eg, Down’s syndrome and neural tube defects), degenerative conditions (prostatic hypertrophy, cataracts, and hearing loss), musculoskeletal problems (back pain, arthritis, gout), genitourinary conditions (infertility and kidney stones), and mental health problems (depression, schizophrenia).
But what it boils down to, for both the layman and health professional, is the NCD group is neither united by a single thread nor is there a clear criteria that separates all NCDs from classical infectious diseases.
The impact of such a muddled definition on the Pacific biennial health meeting for example, “it makes it hard for politicians and the general public to grasp the main challenges posed by NCDs: a problem that is exacerbated by the implication that individual (rather than societal) factors are the key determinants”. And it also impacts actions, awareness raising and effectiveness of campaigns by health professionals and stakeholders as “it is also clear that the nondescript nature of the current label permits broad interpretation and recruitment of disparate parties, all flying the same banner but with many different agendas.”
The replacement name currently being bandied around for NCDs is: Socially Transmitted Conditions (STCs).
In the Lancet article, STC, together with a number of other alternative names are united by either emphasizing the chronicity of NCDs or the fact they are driven by a common set of anthropogenic – result of human influence – drivers.
Since virtually all diseases are influenced by social factors to some degree, it was stressed that STCs are distinguished by the common group of social drivers they share.
This line of thought stems from the fact that other disease groupings fit neatly into clearly defined threads such as shared pathogenesis (eg, cancers), the systems they affect (eg, respiratory diseases), when they occur in the life course (neonatal and maternal conditions), and common behavioural antecedents (eg, sexually transmitted infections).
Applying the above reasoning, the Lancet article ended up with the assumption that “it is most appropriate to bind NCDs together using their common upstream drivers”. And therefore settled on the term STC as the best ‘name’ for the NCD group for the following reasons:
- This label stresses the anthropogenic and socially contagious nature of the diseases: STCs are driven by urbanisation, industrialisation, and poverty, the availability of tobacco, alcohol, and processed foods, and physical inactivity.
- STCs also share a common set of solutions focused on addressing the complex and often unjust structure of society.
“It is important not to absolve individuals of all responsibility for their own health and lifestyle choices, while highlighting the fact that our changing social environment strongly influences the set of choices available.”
The preface “socially transmitted” shifts the implied locus of action upstream and provides clarity by describing the core-uniting characteristic of the disease group. It is also vastly more transparent, accurate, and tractable than “non-communicable”. More importantly, “it challenges the persisting misconception that individual greed and sloth are driving the global epidemiological transition”.
In summation, the global health sector is now on a concerted drive to replace the name NCD with STC. A change that could bring with it “a coherent and internationally significant narrative [to] stimulate greater action on the major drivers of the world’s most important conditions.”
And this is where Pacific health leaders and officials need to be vigilant with their antennas standing at full alert. To take note and prepare to respond and re-align actions in the not too-distant future if and when the name NCD is replaced by ‘socially transmitted conditions’ or some other alternative.
This is critical as current actions to combat ‘NCDs’ have been focused on the “individual”, while the new STC term will shift global actions and major strategies to combat the prevalence of STCs which revolve around three major drivers: urbanization, industrialization and poverty.
Is the Pacific health sector ready to action such a re-alignment? Will the actions signed-off by health ministers at the 12th biennial meeting on 28-30 August 2017 inclusive of a potential fork on the NCD road shifting focus from the individual and onto urbanization, industrialization and poverty? Will it consider implications for the upcoming 2018 UN High-Level Review on NCDs, which will examine progress achieved in the prevention and control of NCDs; and possibly a new round of political commitments. As well as possible changes in line with progressing the 2030 Agenda for Sustainable Development?
There is confidence that at the Fifth Heads of Health meeting on 25-27 April in Suva, Fiji that senior health officials from 22 Pacific Island countries and territories along with regional and international health professionals have got the situation under control.