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Friday, March 04, 2016

chronic Diseases

Richard Horton (Dec 12, p 2378)1 makes a much needed critique of the non-communicable disease (NCD) movement, or rather, the absence thereof. How much does this stagnation have to do with the power of the “legal (if not loved) multinational corporations”? And how much does the power of Big Alcohol have to do with the complete absence of an adequate focus on alcohol in the NCD arena, including Richard Horton's critique?
Alcohol contributes 5·9% to deaths globally.2 Of alcohol-attributable mortality, 33% is attributable to cardiovascular disease and diabetes, 12% is attributable to cancer, 16% to gastrointestinal disease, and 12% to neonatal disorders.2 Yet Richard Horton's list of example risk factors is tobacco, diet, physical inactivity, high blood pressure, and air pollution.
The NCD movement must provide a clear critique of the role the food and alcohol industry as well as the tobacco industry have in the NCD crisis. Goal 3 of the Sustainable Development Goals states the need to “strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks”. These industries, with their effects on people's daily lives and their subversion of efforts to regulate their activity, are a global health risk and, rather than being represented as partners in the NCD arena, their conflict of interest needs to be recognised: their accountability is to shareholders' profits. Acknowledgment and action is part of the electric shock the NCD movement needs.
I declare no competing interests.


  1. Horton, R. Offline: Chronic diseases—the social justice issue of our time. Lancet20153862378
  2. WHO. Global status report on alcohol and health 2014. 12, 2014. ((accessed Dec 15, 2015).)
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        • With his recent commentary, Richard Horton (Dec 12, p 2378)1 created a much-needed jolt in the non-communicable disease (NCD) community.
          We agree with many of the points Richard Horton raised. NCDs are complex, and fighting them is our generation's greatest challenge. That same complexity demands that progress be at a less than blistering pace. And yes, let us acknowledge that we in the NCD community are too polite and not impatient enough. We talk incessantly to each other—at conferences, WHO meetings, and UN side-events—and are not pulling the rest of the world community along. We have not figured out how to tell compelling stories of strapping 25-year-old people who get cancer, of women who have quit their jobs to care for a mother-in-law with heart disease, of a poor family going deeper into the abyss of poverty because of one person's diabetes, of a woman hunched over an open cook-stove inhaling fumes that increase her risk for chronic obstructive pulmonary disease; heart-rending stories of people fighting the stigma of mental disease—stories that should move hearts and minds.
          We take this criticism in the right spirit and are determined to learn from those who mobilised the world around HIV/AIDS, maternal, newborn, and child health, and climate change. And we are going to be impolite—yes, that we are.
          But semi-comatose, that we are not.
          People in the NCD community are passionate, determined, hard-working, and collaborative. Some people are inspiring and true leaders. Some people work on persuading governments to make change, others highlight the effect of NCDs on women, whereas others focus on young people. Some people work on proving that workplace wellness is sound business. All of us do soul-stirring work, and we object to being labelled semi-comatose. Can Richard Horton take that word back?
          Several things give us hope. First, we think the 25 × 25 goal that WHO pulled all countries—some kicking and screaming—into agreeing to, in 2012, is bold. It is up to the NCD community to hold the countries accountable and make sure they deliver. Second, non-profits organisations are taking on huge efforts. For instance, Arogya World has completed a 1-million-person diabetes prevention text messaging campaign in India and shown a 15% improvement in health behaviours. The organisation has developed a chronic disease prevention mobile app for working Indians. mHealth is promising, given its broad reach, and once the evidence builds, population-level prevention with government engagement might be the silver bullet. Third, the private sector is at last joining in—in a sensible way. Kudos to Novartis for its Access initiative,2 through which the company will make 15 widely used NCD treatments available at US$1 per month per person—affordable, sustainable, and worthy of emulation. Fourth, financing is the big challenge, but some progress has been made in the development of sustainable ways to pay for the monumental NCD burden. Taxes on tobacco and sugar-sweetened beverages and the implementation of universal health coverage are key. The tax on sugar-sweetened beverages in Mexico, encouraged by the Latin American NCD community,3shows promising results. Finally, going forward, cities and workplaces are smart ways to channel our energy. It is great to see some momentum building around this approach, and we welcome the International Diabetes Federation's diabetes prevention score for cities.
          NCDs have grown to be the century's defining health and development challenge on our watch. Our generation's responsibility is to respond sensibly and creatively to the NCD crisis. We, the NCD community, with organisations big and small, are determined, in ways polite and impolite, to bring the international response to the NCD crisis in line with the scale of the problem. And we are determined to do our bit to ensure that the world we get is the world we want.
          We declare no competing interests.


          1. Horton, R. Offline: Chronic diseases—the social justice issue of our time. Lancet20153862378
          2. Novartis. Novartis launches ‘Novartis Access’, a portfolio of affordable medicines to treat chronic diseases in lower-income countries. 24, 2015. ((accessed Jan 26, 2016).)
          3. Colchero, MA, Popkin, BM, Rivera, JA, and Ng, SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ2016352h6704

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