There is no time to lose: An urgent call for meaningful action to reduce NCDs
HRH Princess Dina Mired of Jordan, President of the Union for International Cancer Control (UICC)
This article is based on the keynote speech delivered by Princess Dina Mired to delegates at the Third United Nations High-Level Meeting on Non-Communicable Diseases (NCDs) in 2018 as “Eminent Champion of NCDs”. Princess Dina, President of UICC, reflects upon the progress that has been made since 2011, the signing of the first Political Declaration on NCDs and where we still need concerted action to reduce the tremendous burden of cancer and other NCDs in countries around the world.
In September 2018, I was invited to speak at the United Nations for the Third High-level Meeting (UNHLM) of the General Assembly as “Eminent Champion” on the prevention and control of non-communicable diseases (NCDs). This was the second time that I addressed the General Assembly on this important health issue.
Seven years and seven days before my 2018 speech, I gave the keynote speech at the first High-level Meeting on NCDs. At the time, in 2011, standing at the solemn podium, I felt the gravity of the occasion, not just as a keynote speaker on behalf of civil society, but as the voice of 36 million souls worldwide who were dying from the leading diseases of our time: cancer, diabetes, heart disease, chronic respiratory disease and mental illness. I thought especially of those living in low- and middle-income countries (LMICs), who bear the brunt of the global NCD burden with very little access to global resources. And yet despite the solemnity of the task, during the preparation of my speech, words poured out so easily. In fact, it felt like my speech literally wrote itself in one go.
In 2011, we had to debunk the myth that NCDs only affect high-income countries, and we had to impress upon world leaders to add a new acronym to the big list of UN acronyms. When we spelled out the letters “N”, “C”, “D”, we etched non-communicable diseases front and centre on our list of diseases to address immediately. We, the passionate, committed players in civil society, all felt that we had finally hit the big league.
However, this time around, I confess that I struggled to develop my speech. I wrote, rewrote and crumpled many papers and was altogether at a loss for words, driven by deep bafflement as well as great concern about the slow progress since the UNHLM in 2011.
In fact, according to a recent study entitled “NCD Countdown 2030,” published by The Lancet with collaboration from the World Health Organization (WHO), the NCD Alliance and Imperial College London, UK, we know that more than half of all countries are not on track to meet the Sustainable Development Goal (SDG) 3.4 target to reduce premature mortality from NCDs by one-third; and mortality from the four NCDs included in SDG target 3.4 has stagnated or increased since 2010 among women in 15 (8%) countries and men in 24 (13%) countries (1).
Furthermore, in 2018, it was estimated that there were 18.1 million new cancer cases and 9.6 million deaths from cancer (2). This alarming growth in cancer incidence and mortality, from 14.1 million and 8.2 million respectively in 2012, underscores the urgency at hand. Certainly, these are disheartening statistics, given the enormity of the challenge and the encompassing injustice wreaked on the afflicted.
What is puzzling is that this current grim landscape prevailed even though since the first UNHLM in 2011, civil society organizations and WHO have worked tirelessly to support countries in their fight against NCDs. We advocated hard for the framework to have global targets with the overarching goal to reduce premature mortality 25% by 2025. Then, we argued that NCDs are a development issue and not simply a health issue, making the political and economic case for them to enter the club of the SDGs. Together, we reframed our call to action in dollar terms, to ensure that finance ministers would understand that investing in NCD prevention, treatment and cure is not only a sound economic decision but also a high-yielding investment. We have shown that investing US$ 1.27 now on NCD prevention will yield a return of US$ 7 per year in 2030, totalling US$ 350 billion dollars (3).
We advocated for an investment in health systems so that individuals can access the services they need through the life course and along the continuum of care, from prevention and early detection of NCDs to treatment and care, as well as palliative care and survivorship.
In parallel, we have supported and developed evidence-based tools and guidance documents, as well as initiatives such as the Global Initiative for Cancer Registries (GICR) and the RESOLVE initiative. We even rolled up our sleeves and put boots on the ground through initiatives like the City Cancer Challenge founded by UICC and the Bloomberg Partnership for Healthy Cities, which support cities in developing strong, sustainable and impactful cancer and NCD programmes at city levels. The work of our colleagues at WHO have given us a suite of “Best Buys” for all countries based on the best available scientific research to take efficient and cost-effective action on NCD prevention, treatment and care no matter their income levels.
With these actions, we erased the assumption “we don’t know what to do”, we erased the “no money argument”, and we nullified the notion of the impossible, the challenging and the complex. Yet, 15 million people are still dying prematurely every year right before our eyes (4). It is for these reasons that I was at a loss for words. After all, how many times does one need to explain the obvious and the urgent to spur serious and meaningful action? What else should we do to get the political and economic attention needed for implementation on the ground?
We understand the challenges that heads of states and health ministers face, especially in resource-challenged countries, can be formidable. A health minister who for so long only focused on communicable diseases like malaria, Tuberculosis and HIV must now find the funds to purchase medicines and technologies, as well as provide quality human resources, to manage NCDs, often without a global-type fund or other international assistance.
Sometimes, it seems that it is easier to fund weapons to wage war that destroys human lives than it is to financially support the actions that will save them. But, as Martin Luther King Jr said, “We refuse to believe that the bank of justice is bankrupt”.
While we understand the often competing and difficult decisions that governments face with scarce available resources, we have also walked in the uncomfortable and distressed shoes of patients who must make the unconscionable decision about whether to put food on the table or to get their lifesaving medications, and that is if that medicine is even available, affordable or accessible. As President of UICC and the former Director General of the King Hussein Cancer Foundation, I have witnessed this inequity at first hand during visits to various developing countries.
We need to understand what it is that is paralyzing some countries from doing more of the right thing? Perhaps, we all have to remind ourselves that we cannot simply wish these diseases away. These diseases are here to stay unless we act to stop them. I often say that NCDs are the “serial killers” of our time. They are non-discriminate, expansive, consistent, swift, strategic and certainly very comprehensive and universal in their approach. But what accelerates their deadly work is our own fragmented, indecisive and inactive approach.
And yet, there are a multitude of new opportunities available to us to take decisive action on NCDs. We must seize these opportunities to implement the programmes and services in cancer and other NCDs and make a real difference in people’s lives, both to limit the likelihood that people develop NCDs and to manage them effectively.
As I stood on the podium at the 2018 UNHLM, I did not want to focus my speech only on how and why we were not meeting our global commitments, but also to bring forward some of the recommendations of civil society organizations working on NCDs in communities around the world.
These recommendations include the following:
- Let us advocate for universal health coverage (UHC). UHC has emerged as an international policy priority in health and development. UHC seeks to ensure that people access the health services that they need, that are of high quality and efficacy, and that people are not put into financial difficulty in accessing them. This is welcome news for cancer control, as well for other NCDs. Many countries around the world are developing national UHC plans, which will include essential health services across communicable and non-communicable diseases.
It is possible for every country, regardless of income level, to include some cancer control interventions in the national UHC package. For example, in countries with high breast cancer and cervical cancer rates, HPV vaccination campaigns can be rolled out along with cervical screening and/or breast cancer awareness in conjunction with other services at primary healthcare level, such as family planning, maternal and child health programmes and HIV/AIDS programmes. In this way, UHC can be progressively achieved so governments do not have to cover “everything at once”.
- Let us heed the global call to action by the Director General of the World Health Organization in May 2018 to eliminate cervical cancer.
To achieve its elimination, we need action on three fronts: 1) to increase the coverage of vaccination against human papilloma virus (HPV); 2) to increase cervical screening coverage with rapid and appropriate management of women who screen as positive; and 3) to reduce deaths from cervical cancer through promoting early access to treatment and care, including palliative care.
This global initiative on cervical cancer – one of the most preventable cancers – can transform the lives of girls and women and render cervical cancer once and for all to the annals of history.
- Let us ensure that NCDs are a priority item on the cabinet ministers’ agenda, not just the health minister, the whole of the government’s agenda.
- Let us develop and implement national NCD plans, as well as National Cancer Control Plans (NCCP), in all countries. These plans should be endorsed by the Head of State and contain a detailed budget, as well as targets and time-bound commitments.
- Let us achieve an increase in the level of funding available at national level for NCDs from all sources, including domestic, bilateral, multilateral and innovative financing by 2025.
- Let us invest seriously in NCD prevention to stop the factories of disease. Also, let us invest in early detection and treatment interventions that we know are effective in reducing the burden of NCDs. These are detailed in WHO’s evidence-based “Best Buys” to fight NCDs.
- Let us make vaccinations available in all countries to reduce the incidence of infection-based cancers.
- Let us tax the industries that break us, instead of giving them a tax break. Let us implement the regulatory and fiscal measures such as front-of-pack labelling; marketing restrictions on foods and drinks to children; healthy fiscal policies, including taxes on sugary drinks and subsidies on fruit and vegetables; and the promotion of healthy environments that guarantee physical activity and access to safe drinking water and healthy food.
- Let us legislate against industries that are intent on profiting at the expense of our health. Starting with the tobacco industry. Let us call for full implementation of the Framework Convention on Tobacco Control (FCTC) to stop them owning the best real estate in the world – the millions of youthful lungs consuming their deadly product.
- Let us invest in NCD surveillance data to track, monitor and report in 2025 on the progress we have made.
Yes, it can be done. We have seen some shining examples of what can be achieved with political will. Many countries have already established NCD plans, and a growing number of countries have “operational plans,” which means that plans are “off the shelf” and being implemented.
In the 15 years I spent as Director General of the King Hussein Cancer Foundation, as part of the team that saw the transformation of cancer care in Jordan, I experienced first-hand what political will, planning, organization, systemization and hard work can accomplish.
Seeing 59 Heads of State present at the 2018 UNHLM on NCDs gave me renewed hope and sent a resounding message to all NCD patients and their families that the global community does care about NCDs. I began to see the possibilities for a world where children diagnosed with leukemia in LMICs do not have to accept the inevitability of a measly 10% survival rate for a disease that can be cured in a high-income country. A world, where refugees who have escaped the violence of war do not have to be subjected again to the violence of inaction on NCDs, receiving little or no treatment for their cancer, heart disease or diabetes. A world where refugees are not seen as a special superhuman breed who are only in need of basic emergency services.
I reminded delegates that every letter and every word they agreed to in the political declaration would translate into something real for people living with NCDs. Each delegate can provide insulin, palliative care or essential cancer medications for millions at an affordable price, or, adversely, with a simple pen stroke, can take it all away from those who need it most. Yes, it is very personal and very real.
The writing is on the wall. We are moving decidedly towards an unhealthy and injurious future unless we resolve today to deliver on our promises and accelerate progress. I reminded the delegates that we must ask ourselves what legacy we want our generation to be remembered for. The one that watched the NCD epidemic destroy the lives of our children and our children’s children, or the generation that said enough is enough and took remedial action? The weight of this seminal decision is on all our shoulders, including government, civil society organizations and the multitude of patient organizations who can provide experience and insight into what a patient-centred approach to NCDs looks like.
As Nelson Mandela, one of my heroes, aptly said: “It always seems impossible until it is done”. Let the 2018 UNHLM be the seminal meeting that will finally start to deliver on the ground.