4 Global health policy responses to the noncommunicable disease pandemic

Question 1

Overview Summary

Answer 1

This session provides a broad introduction to the topic of noncommunicable diseases (NCDs). NCDs contribute significantly to the global burden of death and disease worldwide – four sets of NCDs are estimated to have caused 74.5% of all global deaths in 2019. NCDs are a growing concern in both the Global North and South, affecting men and women in rich and poor countries alike. A set of risk factors has been identified as contributing to the majority of NCDs morbidity. In low- and middle-income countries there is a vicious cycle between NCDs and poverty, marginalisation, discrimination, which further contributes to morbidity and mortality. A strong connection has been established between economic growth and controlling NCDs. Finding solutions for curbing the global NCD pandemic, some argue, is a political, not a technical problem. The session will briefly discuss global policy efforts to address the NCD pandemic and will use the case of global tobacco control as a case-study of attempted NCD control.

Question 2

Overview Aims

Answer 2

The aim of the session is to introduce the topic of noncommunicable disease control in global health policy and politics, which includes a discussion of the challenges faced by global governance in this field.

Question 3

Overview Learning Outcomes

Answer 3

By the end of this session you should be able to: Define noncommunicable diseases and identify their associated risk factors; Discuss the impact of globalisation on the spread of noncommunicable diseases; Outline and evaluate existing global health policy and current policy recommendations aimed at addressing the noncommunicable disease pandemic; and Describe and evaluate the global tobacco control regime.

Question 4

Key terms Non-communicable diseases (NCDs):

Answer 4

noncommunicable or chronic diseases are the leading cause of death globally and one of the major challenges of the 21st century (WHO 2018a: 10). NCDs are difficult to define, as all terms used – noncommunicable, chronic, lifestyle diseases - are a misnomer in one way or another (WHO 2011: 35; Allen and Feigl 2017). Broadly speaking these are diseases of long duration, generally slow progression, requiring extensive and specialised healthcare that are not passed from person to person. The 4 main types of non-communicable diseases are cardiovascular diseases (e.g. heart attack, stroke), cancers, chronic respiratory diseases (e.g. chronic obstructive pulmonary disease, asthma) and diabetes.

Question 5

Key terms Modifiable risk factors

Answer 5

four modifiable risk factors have been identified as contributing to global NCD morbidity and mortality – tobacco use, excessive use of alcohol, diet and physical activity. These are referred to as ‘modifiable’, because they can be changed or modified by encouraging changes in individual choices and preferences

Question 6

Key terms Economic globalisation

Answer 6

the intensification of economic activity that crosses national borders – e.g. production, consumption and the movement of people, goods, capital, services – and the growing interdependence of national economies. This process is facilitated by the increased speed and decreased cost of transport and communications.

Question 7

Key terms Framework convention

Answer 7

a specific type of international legal instrument, which sets out broad commitments agreed by the parties, while leaving the setting of specific targets and policies either to individual states or to subsequent agreements by the parties. A framework convention is legally binding on the parties, as much as any international treaty.

Question 8

1. Introduction

Answer 8

Noncommunicable diseases (NCDs) are the ‘leading cause of death globally and one of the major challenges of the 21st century’ (WHO 2018a: 10). It is estimated that over 70% of all deaths globally are attributable to four groups of diseases – cardio-vascular diseases, cancer, respiratory diseases and diabetes (The Lancet 2018; WHO 2018b; Horton 2019). Populations of low- and middle-income countries (LMICs), as well as socioeconomically deprived groups in high-income countries, are at higher risk of developing NCDs and with nearly two-thirds of deaths occurring in LMICs being caused by NCDs, these populations are disproportionately affected by NCDs (Horton 2005; Di Cesare 2013; UNDP 2013: 11-12; WHO 2018b). The risk of dying prematurely from NCDs in a LMIC is almost double that in high-income countries (HICs) (WHO 2018b: 7). Practices associated with the prevention, control and care of NCDs are uneven and inconsistent globally, but particularly insufficient in the same regions and social strata that are most affected by and most vulnerable to these diseases.

Question 9

1. Introduction

Answer 9

The problem of NCDs has often taken the back seat in global health politics, because priority attention and funding has gone to infectious diseases, as they tend to pose an immediate risk and can more easily be framed as a security threat. There is therefore a paradox between the high morbidity and mortality caused by NCDs and the political attention and funding that they receive.

Question 10

1. Introduction

Answer 10

While four modifiable risk factors for the reduction of the incidence and prevalence of NCDs have been identified – tobacco use, harmful use of alcohol, diet and physical activity (WHO 2013), meaningful change and progress towards meeting global commitments to curbing the NCD pandemic is yet to be achieved. There is a multitude of reasons for this, which are proving complex and difficult to address or resolve. This session will discuss the scope of the NCD pandemic and consider the political economy of NCDs, thus considering the economic, social, political and legal context within which global health policy on NCDs is made and implemented. Economic factors, considered to affect NCD policies include global trade, free market economy, poverty, inequality and underdevelopment. Social debates often revolve around questions such as whether NCD prevention is an individual responsibility and can therefore be addressed through behaviour-focused policies or whether there are structural causes and determinants of NCDs, or indeed both and what a policy to address these might look like. Political discussion of NCDs focus on questions of power and global governance, with considerations of the power of multinational corporations (MNCs) in relation to that of sovereign states, the power of public-private partnerships, the architecture of global governance for health, questions around leadership, etc. The legal context is an important factor in finding solutions to the global pandemic - the problem of NCDs exists in a much broader and complex international and national legal and normative context, which shapes the possibilities of legal regulation of aspects of NCD prevention and care.

Question 11

1. Introduction

Answer 11

The session will then conclude with a discussion of the Framework Convention on Tobacco Control as a case study of the politics of NCDs and briefly discuss it in comparison to other global approaches to NCDs.

Question 12

2. Scope of Noncommunicable disease pandemic

Answer 12

This section will discuss the noncommunicable diseases (NCDs) in focus in current global discussions and policy-making efforts. It will also briefly discuss the identified risk factors and highlight the debates around these – namely, while the factors are not disputed, some believe that these factors put too much responsibility on individuals, while discounting structural factors, the role of corporate interests and activity worldwide, in seeking solutions to the NCD pandemic.

Question 13

2.1 Noncommunicable disease groups

Answer 13

Noncommunicable diseases appear under different names – chronic diseases, lifestyle diseases, noncommunicable diseases. Neither of these terms is particularly accurate and/or effective, some argue (Allen and Feigl 2017). ‘Chronic’ refers to important shared features – these are diseases of long duration and an epidemic that takes a long time to become fully established; they require a long term systematic approach to treatment; health services must integrate their response to these diseases with responses to acute, infectious diseases (WHO 2005: 35). The issue with this is that some infectious diseases – such as HIV/AIDS can also be defined as chronic in view of the need for lifelong treatment. The term ‘noncommunicable’ sets these diseases in opposition to infectious or ‘communicable’ diseases – the term is not entirely accurate, as some cancers are caused by viruses. ‘Lifestyle-diseases’ is a term sometimes used to describe the contribution of behaviour to the onset of NCDs, but there is significant evidence about the influence of environmental factors, while ‘life-style’ choices may also be contributing factors to communicable diseases (WHO 2005: 35). Currently, the most widely used term is noncommunicable diseases (NCDs), which does not take away from the characteristics as referred to in other terms.

Question 14

2.1 Noncommunicable disease groups

Answer 14

The leading non-communicable disease groups - cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – are to a large degree caused by modifiable risk factors - tobacco, alcohol, poor nutrition, and physical inactivity; but also, by non-modifiable risk factors – e.g. age and heredity, environmental factors.

Question 15

2.1 Noncommunicable disease groups Cardiovascular diseases

Answer 15

A group of disorders of the heart and blood vessels including: heart attacks (coronary heart disease), stroke (cerebrovascular disease), raised blood pressure (hypertension), peripheral arterial disease (affects blood vessels supplying arms and legs), blood clots (deep vein thrombosis and pulmonary embolism) and others including peripheral artery disease, rheumatic heart disease and congenital heart disease. CVDs are the leading cause of death globally – more people die of CVDs around the world than from any other cause (WHO 2017). An estimated 17.9 million people died from CVDs in 2019, representing 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke. Over three quarters of CVD deaths took place in low- and middle- income countries (WHO, 2021a).

Question 16

2.1 Noncommunicable disease groups Cardiovascular diseases

Answer 16

The most important behavioural risk factors for heart disease and stroke are unhealthy diets, physical inactivity and tobacco use. Behavioural risk factors are responsible for about 80% of coronary heart disease and cerebrovascular disease. Harmful alcohol consumption causes at least 3.3 million deaths every year, this represents 5.9% of all deaths. Obesity and overweight (BMI < 25 is overweight, a BMI< 30 is obesity): In 2014, more than 1.9 billion adults (<18 y) were overweight.

Question 17

2.1 Noncommunicable disease groups Cancer

Answer 17

As the WHO sets out ‘cancer is a generic term for a large group of diseases, characterised by the growth of abnormal cells beyond their usual boundaries that can then invade adjoining parts of the body and/or spread to other organs’ (WHO 2021b). Cancer can affect almost any part of the body. Cancer is estimated to be the second leading cause of death globally, estimated to have caused nearly 10 million deaths in 2020 (WHO 2021b). Approximately 70% of deaths from cancer occur in LMICs (WHO 2018c).

Question 18

2.1 Noncommunicable disease groups Cancer

Answer 18

Risk factors for cancer include harmful levels of alcohol consumption, which can lead to risk for cancer of: oesophagus, colorectum, breast, endometrium, and kidney; use of tobacco products, which increases the risk of lung and breast cancer; unhealthy diets high in saturated fats, sugar, salt; inactivity and obesity, which can lead to increased risk for cancer of: oral cavity, pharynx, larynx, oesophagus, liver, colorectum and breast; and others. Non-modifiable risk factors for cancer include chronic infections (hepatitis B and C virus and some types of Human Papilloma Virus); environmental pollution (air, water and soil containing carcinogenic chemicals, which account for 1–4% of all cancers); occupational exposure to carcinogens (asbestos-related mesothelioma is a key example); and radiation (residential exposure to radon gas from soil and building materials accounts for between 3% and 14% of all lung cancers).

Question 19

2.1 Noncommunicable disease groups Respiratory diseases

Answer 19

The most significant chronic respiratory diseases according to the Global Alliance against Chronic Respiratory Diseases are: Asthma (262 million people suffered from asthma in 2019, leading to 461,000 deaths); Chronic obstructive pulmonary disease (COPD – 90% of COPD deaths occur in LMICs); Respiratory allergies; Bronchiectasis; Obstructive sleep apnoea syndrome; and Pulmonary hypertension.

Question 20

2.1 Noncommunicable disease groups Respiratory diseases

Answer 20

The most important modifiable risk factor for preventable chronic respiratory diseases is tobacco smoking, which includes second-hand tobacco smoke exposure. Non-modifiable risk factors include - indoor cooking and heating using biomass fuels such as wood, animal dung and crop residues (this practice is common in rural India and many other Asian countries); outdoor air pollution and allergens; occupational risks.

Question 21

2.1 Noncommunicable disease groups Diabetes

Answer 21

Diabetes is a ‘chronic metabolic disease, characterised by elevated levels of blood glucose, which leads over time to severe damage to the heart, blood vessels, eyes, kidneys and nerves’ (WHO 2018d). Around 422 million people around the world have diabetes, with diabetes prevalence raising more rapidly in LMICs (WHO 2018d). Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin by itself (WHO, 2021c). Type 2 Diabetes (non-insulin-dependent) accounts for 90% of all global diabetes cases. Diabetes is primarily caused by diet, obesity, and lack of exercise; tobacco use can contribute to the onset of diabetes. More than 80% of diabetes deaths occur in low- and middle-income countries. Diabetes increases risk of other diseases. – such as heart disease and stroke, neuropathy, kidney failure. The extent of medical care for individuals with diabetes is three to four times larger than the care required by people who do not have the disease, putting a significant burden on health systems worldwide. In 2016 the WHO produced the Global Report on Diabetes discussing the extensive spread of the disease and calling governments to action to step up efforts to prevent and treat diabetes more effectively.

Question 22

2.2 Modifiable behavioural risk factors

Answer 22

The modifiable risk factors as listed above include tobacco use, excessive alcohol consumption, unhealthy diets – associated with the consumption of saturated and trans fats, sugar and salt, insufficient physical activity. We saw that each of these factors is associated with at least two and often more of the four groups of noncommunicable diseases. In other words, controlling risk factors and changing individual choices and behaviour would have multiple benefits. These risk factors have often been referred to also as behavioural risk factors, because they are associated with particular individual behaviour and modifiable choices.

Question 23

2.2 Modifiable behavioural risk factors

Answer 23

Governments and non-governmental actors have committed to a series of efforts to prevent NCDs through actions to affect modifiable risk factors. This commitment is illustrated by global strategies and action plans, agreed at the UN and WHO, starting with the Global Strategy for the Prevention of Noncommunicable Diseases in 2000. The most significant and committed global effort in this respect is the creation of the Framework Convention on Tobacco Control, which is a legally binding international agreement that will be discussed later in this session. Governments also take national level action by introducing national legislation, strategies, and action plans. National level action often revolves around programmes to encourage physical activity, regulate salt, and sugar intake, create and enforce legislation to ban smoking in public places, etc.

Question 24

2.3 Nonmodifiable risk factors

Answer 24

Contributory factors to the rising prevalence of NCDs include living conditions and lifestyles and their influence on health and quality of life. Poverty, the uneven distribution of wealth (inequality), lack of education, rapid urbanization, globalisation, population aging, the general policy environment are sometimes referred to as underlying determinants (or causes of the causes) (WHO 2005: 51). Noncommunicable diseases are both a cause and a consequence of poverty and marginalisation (Hosseinpoor et al 2012a and 2012b; DiCesare et al 2013: 593; UNDP 2013). NCDs are also considered a barrier and/or a major challenge to development (UNGA 2012: 1; Reubi et al 2016: 179-180). Beaglehole and Yach (2003) argued that globalization is an important determinant of the noncommunicable disease epidemic.

Question 25

2.3 Nonmodifiable risk factors

Answer 25

Global trade liberalisation rules and agreements, and the freedom and power that corporations must seek the least regulated politico-economic spaces to produce and trade tobacco and alcohol products, and the capacity that such corporations have to resist development country efforts to hold them accountable, illustrate some of the ways in which globalization affects NCD incidence and prevalence (Tangcharoensathien et al 2017: 359-360). This theme will be discussed in a later section. Globalisation with its ‘free movement of capital, technology, goods and services, has [had] a significant effect on lifestyles’ in LMICs and HICs alike (Wagner and Brath 2012: s40). The increases in morbidity and mortality associated with NCDs also has a significant impact on economy, with estimated losses in national income from leading NCDs ranging from 3 to 18 billion in 2005 in countries such as Brazil, India, China, the Russian Federation (Wagner and Brath 2012: s39). The feedback therefore between economic causes and consequences of NCDs is prominent, particularly so in LMICs.

Question 26

Actvity 1 Research your country’s approach to curbing NCDs – this could include legislation, strategies, action plans. Share your findings and a paragraph-long reflection on the scope, scale and direction of these efforts.

Answer 26

Post your responses in the discussion forum and comment on the reflections of at least two other students.

Question 27

3. Impact of Noncommunicable diseases

Answer 27

The impact of noncommunicable diseases is multidimensional. NCDs directly affect those suffering from them, but also their immediate family. These diseases put a strain on personal resources and on health systems, as well as on the economy. This section examines these impacts in further detail.

Question 28

3.1 Morbidity and mortality

Answer 28

As already noted, estimates of the global burden of noncommunicable diseases vary, but a number of sources put global NCD-related mortality at around 73% of all deaths worldwide in 2017 (The Lancet 2018; WHO 2018b; Horton 2019). More than 82% of all deaths from noncommunicable diseases (cardio-vascular diseases, respiratory diseases, cancer and diabetes) are said to occur in low- and middle-income countries (LMICs). Every year, 15 million people between the age of 30 and 69 die of NCDs. These deaths are considered premature. 85% of NCD-related premature deaths occur in LMICs (WHO 2018e). Many of these deaths are preventable as they are associated with modifiable risk factors, as discussed in the previous section.

Question 29

3.1 Morbidity and mortality

Answer 29

NCD morbidity can be characterised as being long-term and one for which a complete cure is rarely available. In most cases treatment for NCDs requires lifetime medication and frequent use of medical services. With the NCD burden of morbidity and mortality growing in LMICs and with much of medication and care being paid out of pocket, populations in these countries suffer a double economic burden – through rising healthcare costs and falling income. Furthermore, as discussed in the previous section, some NCDs more than others, are prone to complications and heightened risk of functional impairment and disability, adding to the vicious cycle between poverty and NCDs, but also contributing to underdevelopment and inequality.

Question 30

3.1 Morbidity and mortality

Answer 30

Studies are beginning to emerge that demonstrate multimorbidity associated with NCDs, complicating this pandemic further, as in some cases nearly one third of studied NCD-sufferers develop two or more NCDs (Mini and Thankappan 2017; The Lancet 2018; Licher et al 2019). There are significant resource implications of multimorbidity - namely, complex care needs, the need to train physicians beyond one specialist area, the need for specialist technology to support patients’ self-management of multimorbidity, integrating care in new treatment centres set up for multimorbidity (The Lancet 2018: 1637). As The Lancet article concludes, multimorbidity is extremely costly to both individuals and health-care systems. These findings should add a significant impetus to global efforts to prevent and treat NCDs, because failure to take action now is likely to have serious economic, social and political implications in the not-so-distant future.

Question 31

3.2 Poverty, inequities and underdevelopment

Answer 31

As well as a health impact, chronic diseases have an enormous socio-economic impact - particularly on the poorest communities between and within countries. The political declaration from the first UN High Level Meeting on the Prevention and Control of NCDs in 2011 noted the concern of policy-makers with the vicious cycle of poverty contributing to the rise of NCDs and the prevalence of NCDs and their risk factors worsening poverty (UNGA 2012: 4). A report from the African Union in April 2013 found that the exorbitant costs of NCDs are forcing 100 million people in Africa into poverty annually. Unless addressed the NCD crisis could cost up to USD30 trillion in treatment costs by 2030, estimated as 48% of global GDP (Kamineni 2019). Another way to look at the cost of NCDs is as a USD47 trillion in lost gross domestic product globally from 2011 to 2025 (Ghebreyesus 2018: 1973).

Question 32

3.2 Poverty, inequities and underdevelopment

Answer 32

The figure 1 below illustrates the relationship between poverty and non-communicable disease. Low-income households- represented in the top box - are characterised as being affected by one or more of modifiable behavioural risk factors – e.g. malnutrition and poor diet, physical inactivity, tobacco and alcohol use.

Question 33

3.2 Poverty, inequities and underdevelopment

Answer 33

The economic impact of NCDs, therefore, has an individual and a collective aspect. The individual aspect refers to the impact of NCDs on individual patients and their families – which is the dimension most often associated with poverty and marginalisation, where the latter contribute to the onset of NCDs and are then further entrenched by NCD morbidity as a result of loss of income, costs of treatment and medication. The collective aspect is associated with the cost of treatment to the health system - in terms of scarce and specialised resources required to provide continual treatment, resources being taken away from communicable disease care and general strain on weaker health systems, lost productivity, absenteeism, lost income by both patients and caregivers, reduced labour supply, reduced workforce productivity, which in turn affects the economy overall and is an obstacle to development and economic growth (Council on Foreign Relations 2014: 13-18).

Question 34

3.2 Poverty, inequities and underdevelopment

Answer 34

As well as this disparity between countries in the burden of NCDs, there is also an imbalance within countries between rich and poor people. Smoking and poor dietary habits are increasingly associated with lower socio-economic groups in high income countries, and these same groups generally have inferior access to health care, affecting poor health outcomes and contributing to premature deaths. Other factors include community deprivation and gender inequality.

Question 35

3.3 Security

Answer 35

While a significant burden of NCDs, much like a significant burden of communicable diseases (e.g. HIV/AIDS), can become politically destabilising, it is highly unlikely that NCDs can become a cause of inter-state insecurity or conflict. As the leading cause of death globally, however, NCDs pose the greatest risk to individuals’ lives and therefore the most significant existential threat to people. If security is conceptualised as the elimination of existential threats (threats to life/existence), then NCDs are the leading cause of individual insecurity and premature mortality. As such, they require priority attention both nationally and globally. Individual health security, Richard Horton argues, and prevention and treatment of NCDs can best be achieved through the pursuit of universal health coverage (Horton 2017: 346). Saha and Alleyne (2018) also advocate the framing of NCDs as a global health security issue because of ‘the magnitude of the epidemic of noncommunicable diseases, their increasing prevalence, global costs, potential to overwhelm the response capacity of low-income countries and their contribution to the inequality of health’ (2018: 792). The Centre of Disease Control and Prevention in the USA also notes that high NCD morbidity also increases the risk and severity of communicable disease outbreaks.

Question 36

3.3 Security

Answer 36

Associated with health security are important questions about NCD prevention, treatment and care in conflict, humanitarian crisis and fragile states. Such already complex environments pose specific challenges to those already suffering from NCDs, but also for prevention programmes and continuity of care.

Question 37

4. Global governance and NCDs

Answer 37

Global governance in the early 21st century looks very different from governance and international politics even just three decades ago at the end of the Cold War. Contemporary governance is more accurately labelled ‘global’, because politics above the national level is no longer a realm reserved for, or indeed dominated by sovereign states, and inter-governmental organisations (IGOs). A significant role, particularly in governance related to economic affairs, is now played by multinational (or transnational) corporations, civil society organisations, philanthropic foundations, public-private partnerships, etc., in addition to states and IGOs. This section is going to briefly discuss the architecture of contemporary NCD-related global governance in the context of intensifying globalisation, lead actors and the way in which they affect NCD-related politics.

Question 38

4. Global governance and NCDs

Answer 38

For the purposes of this discussion, we will define global governance as ‘the sum of the many ways individuals and institutions, public and private, manage their common affairs. It is a continuing process through which conflicting or diverse interests may be accommodated and cooperative action may be taken. It includes formal as well as informal arrangements that people and institutions have agreed to or perceive to be in their interest’ (Commission on Global Governance 1995: 2).

Question 39

4.1 Globalisation

Answer 39

The term ‘globalisation’ is widely used and often poorly defined. For the purposes of this session, we are only going to focus on economic globalisation, which is characterised by the intensification of economic activity that crosses national borders – e.g. production, consumption and the movement of people, goods, capital, services – and the growing interdependence of national economies. This process is facilitated by the increased speed and decreased cost of transport and communications. Critical scholars point out that globalisation is uneven; that the possibilities it presents are unequally distributed; that not everyone benefits from globalisation; that it deepens and entrenches current inequalities (wealth, access to resources, ownership of resources) and is often a force of exclusion for the already poor and marginalised, thus disadvantage them further.

Question 40

4.1 Globalisation

Answer 40

Economic globalisation can also be seen in political terms as the decentralisation of political influence and power. As we will see in the next part of this section, many multinational corporations are richer and more powerful than most states. With such power comes influence and interests, which in turn brings fundamental change in the architecture and dynamics of international and national policy-making. As a result of economic globalisation and the intensification of cross-border travel and communications, there are a lot more private actors (for profit and not-for-profit) in the international arena who participate and contribute in various capacities to drafting policies to address the NCD pandemic. Such actors are by no means of equal power or influence, so power differentials and unequal representation of interests continue to characterise policy processes at each level of governance.

Question 41

4.2 Actors Multinational corporations

Answer 41

The rapid growth of multinational corporations is perhaps the most recognisable aspect of economic globalisation. ‘Multinational corporations are a particular form of nongovernmental actor organised to conduct for-profit business transactions and operations across the borders of three or more states’ (Karns and Mingst 2010: 20). A multinational corporation comprises an incorporated network of specialised but interdependent operating units that focus on either a single product, or a range of products and services. Their operations are overseen by an integrated operating system that manages assets, resources and personnel to create global-scale efficiencies and national-level responsiveness that allows for exploitation of worldwide opportunities. This structure enables corporations like Siemens, Diageo, BP and Philip Morris International to operate in “near real time” and circumvent the traditional system of arm’s-length economic transactions and international legal mechanisms. Regulating the activities of multinational corporations by means of legal instruments can be a complex endeavour. As private actors, MNCs are not regulated by international law, which only binds and regulates the behaviour of states. MNCs often operate in a number of national jurisdictions – e.g. are incorporated in one country, have a production line in another, trade in a third and so on – which means that if taken to a national court, corporations must be treated as foreign nationals (under special provision called ‘private international law’). This is not the case everywhere around the world – OECD, for example, has created a model for regulating MNCs, according to which foreign MNCs are to be treated as domestic corporations, but this rule is not universal. To add to these technical specificities, MNCs possess and govern enormous economic resources and therefore wield significant influence in political, economic or other negotiations. MNCs are a source of foreign direct investment (FDI), they are employers and tax payers, manufacturers, which adds to the political influence backed up by their pure economic might, multiplying their bargaining power even further.

Question 42

4.2 Actors Multinational corporations

Answer 42

There are extensive debates in international relations regarding the power of corporations and their place in the global governance architecture. Babic et al. (2018) provide an illustrative, albeit basic comparison between the monetary power of states and corporations, suggesting that in economic terms the respective power of the biggest states and MNCs is on par with one another. As figure 2 below illustrates, of the top 100 revenue generators, 71 are MNCs. Put in other words 71 MNCs generate more revenue than approximately 160 states in the world. This illustrates a staggering discrepancy in resource capability between states and MNCs.

Question 43

4.2 Actors Multinational corporations

Answer 43

MNC investment in low- and middle-income countries often modifies patterns of production and consumption, in some cases access to food and goods. The current global climate of trade liberalisation, free flow of capital and investment, facilitates MNC expansion but also MNC mobility, which is another aspect of their bargaining power (by means of the threat of dis-investment). The financial power, political influence and mobility of MNCs make it difficult for states to apply effective regulations. The benefits that MNC investment bring entices governments to cut taxes, open national markets, modify legislation, even to default on international agreements or promises such as commitments to addressing behavioural risk factors associated with NCDs. While local production of unhealthy foods, alcohol and tobacco products has existed in most, if not all, markets prior to TNC entry, global corporations fundamentally alter the market via their aggressive marketing, political influence and economies of scale. In discussing the political economy of NCDs, Thompson and Garry note that the challenge of NCDs reveals ‘the power of corporations over states and the limits of the health sector to impact population health’ (2019: 1186). For further discussion of the relationship between MNCs and public health related to NCDs and their risk factors see for example Cohen (2011), Hastings (2012), Buse et al (2017) or The Lancet (2019).

Question 44

4.2 Actors Civil Society Organisations

Answer 44

Civil society organisations (CSOs) are private, not-for-profit organisations set up by individuals and groups, who come together to achieve a common purpose and/or promote shared values, empowering individuals and giving voice to groups that are often underrepresented or unrepresented. CSOs can take many forms – social movements, nongovernmental organisations, advocacy networks, charities, trade unions, religious groups, humanitarian aid providers, and other forms of civil associations. These all differ in their structure, purpose, organisation, funding model, etc. Some are more independent, others may be funded or part-funded by governments or indeed multinational corporations. The power of CSOs and this is one important aspect in which they differ from philanthropic foundations for example (which can also be defined as not-for-profit) often stems from their appeal to the broader public, their desire to represent unrepresented voices, their strive to influence policy processes in the greater interest, their ability to collect and disseminate information.

Question 45

4.2 Actors Civil Society Organisations

Answer 45

CSOs can be global, national, regional, local, grassroots. Their influence comes from different sources and their varying specialisms – some organisations are good at gathering information, producing reports, at delivering humanitarian assistance in war-torn countries, advocating for certain causes, to name but a few. CSOs can engage in global governance directly, indirectly or through resistance. They can be involved in negotiations or in consultation. Through accreditation they can gain observer or consultative status with UN agencies and other global governance bodies. They can seek to influence policies through third parties – businesses, forums, trade unions, etc. CSOs can also lead various forms of resistance in global and local politics through protests, support for marginalised communities, lead campaigns to boycott MNCs and so on (Scholte 2014: 322-334).

Question 46

4.2 Actors Civil Society Organisations

Answer 46

In the case of NCDs, scholars have noted that civil society engagement is somewhat slow and limited, which may in part explain the slow progress made by states in affecting change (Yang et al 2018), Geneau et al (2010) note the paucity of global civil society groups and limited presence of local groups and coalitions to put pressure on governments to act on noncommunicable diseases. Analysts further note the under-representation of diverse voices from the Global South as a broader reflection of power distribution at international negotiations (Thompson and Garry 2019: 1187). NCDs appears to be a field where CSOs are not as active or as influential, compared to a myriad of other realms of global and global health policy making. This is an interesting aspect of the field, which requires further study and critical reflection to evaluate its impact and generate a more nuanced understanding of the architecture of governance for NCDs.

Question 47

4.2 Actors States and inter-governmental organisations

Answer 47

States and intergovernmental organisations are still the main drivers of international policy development, including international law, and still the main implementing agencies for existing policy. States are the only actors in the international system that have the formal authority to create international law, due to their exclusive sovereign status. Globally, states and IGOs (mainly the United Nations and the World Health Organisation) have demonstrated a broad commitment to tacking the causes of NCDs and improving treatment and care, as we will discuss in the next section on global health policy for NCDs.

Question 48

Activity 2 Compare (and contrast) the arguments put forward in Hastings (2012) and McKee et al (2014). Which argument do you find more persuasive? Give three reasons why.

Answer 48

Post your thoughts in no more than 2-3 paragraphs on the designated discussion forum and comment on the response of at least two fellow students.

Question 49

5. Global Policy responses to NCDs

Answer 49

This section discusses global policy responses, strategies and action plans to tackle the noncommunicable disease epidemic.

Question 50

5.1 Global Health Policy responses to NCDs

Answer 50

As illustrated in figure 3 below, there is evidence of a concerted and committed global health policy response to NCDs, starting in the year 2000 with the World Health Assembly Resolution WHA 53.14 adopting the Global strategy for the prevention and control of noncommunicable diseases. 2003 marked a significant milestone in global health policy on NCDs with the adoption of the Framework Convention on Tobacco Control. The 2000 WHO Global Strategy on NCDs was followed by two action plans – 2008-2013 and 2013-2020. In 2010, the WHO published the first Global Status Report on NCDs, which for the first time discussed the worldwide epidemic of NCDs, including their risk factors and determinants. Another report followed in 2014, followed by WHO’s Noncommunicable Diseases Progress Monitor (2017). The issue of NCDs was then moved to the United Nations General Assembly agenda by holding the first High-Level Meeting on NCDs, which took place in September 2011. The significance of this meeting is that for the first time heads of state and government formally recognized these diseases as a major threat to economies and societies and placed them high on the UN (not just WHO) agenda. Further UN High-Level Meetings on NCDs were held in 2014 and 2018. In May 2013, the 66th World Health Assembly adopted the Global action plan for the prevention and control of non-communicable diseases 2013-2020 and a comprehensive global monitoring framework with nine voluntary global targets and indicators. In 2013, the United Nations Development Programme published a Discussion Paper Addressing the Social Determinants of Noncommunicable Diseases.

Question 51

5.2 NCDs on the global development agenda

Answer 51

An important global agreement was the Millennium Development Goals (MDGs), established following the Millennium Summit of the United Nations in 2000. When the MDGs were agreed, NCDs were not recognized as a target to include in the sphere of the 8 goals, mainly due to misunderstandings at the time about these diseases, such as: Chronic disease primarily affects high income countries; LMICs should focus on infectious diseases; Chronic diseases primarily affect the elderly; and Treatment is too expensive.

Question 52

5.2 NCDs on the global development agenda

Answer 52

In 2015, building on the gains reached by the MDGs, the United Nations established the Sustainable Development Goals (SDGs). Three specific targets were included to address non-communicable diseases although other targets also apply to NCDs. These are: 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being; 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol; and 3.6: By 2020, halve the number of global deaths and injuries from road traffic accidents

Question 53

5.2 NCDs on the global development agenda

Answer 53

The reduction of the NCD burden is a global development imperative, as argued by Nugent et al (2018). The authors advocate a concerted effort between ministries of health, finance and others, along with investing in addressing NCDs as an economic and development priority, which would contribute to the achievement of other SDGs and ultimately to sustainable and healthy development.

Question 54

5.3 A check on political momentum

Answer 54

There is now a multitude of strategies and specific action plans developed, agreed and ready for implementation - including the WHO Global Action Plan 2013-2020, the Framework Convention on Tobacco Control (FCTC) and its Optional Protocol (2012) to eliminate illicit trade in tobacco products, as well as a number of successful national programs to curb tobacco use. The UN Interagency Task Force on the Prevention and Control of Noncommunicable Diseases set up in 2013 and the WHO Independent High-Level Commission on NCDs established in 2018 are part of a recent acceleration in momentum to do something about the noncommunicable disease burden. Other examples of this new determination include a number of meetings and declarations highlighting the importance of addressing NCDs – such as: WHO’s Preventing chronic disease: a vital investment (2005); Lancet series in 2005/2007/2010/2013; Lancet Taskforce on NCDs and Economics 2018; UN Economic and Social Council (ECOSOC) meeting (2009) and Doha Declaration on NCDs and Injuries (2009); UN Department of Economic and Social Affairs/WHO meeting (2010); UN General Assembly Special Session for the Political Declaration on NCDs (Sept 2011) and High-Level Meetings on NCDs (2014 and 2018); and World Economic Forum ranking chronic disease among leading threats to global economy since 2009.

Question 55

5.3 A check on political momentum

Answer 55

Several efforts to act against NCDs have been unsuccessful or stalled. Of course, this may in part be attributed to the Ebola outbreak in Africa, the COVID-19 pandemic and the other communicable disease outbreaks, which drew the attention of policy-makers away from NCDs. With the publication of WHO’s report Time to Deliver in 2018 and preparations for the UN High-Level Meeting on NCDs in 2025, one could safely say that the issue of NCDs is firmly on the global agenda, but criticisms remain that political will and current levels of investment to address the pandemic are woefully insufficient.

Question 56

5.4 Private sector involvement

Answer 56

In addition to these international declarations, there have also been private sector initiatives. The pharmaceutical industry has recognised the commercial opportunities that may arise from decisions on how best to treat those with chronic diseases. The new urgency around prevention, and fears of litigation similar to that brought against the tobacco industry have brought the food and drink industries to the table. This has led to private-public initiatives such as the Oxford Health Alliance which includes government health departments, academic institutions as well as pharmaceutical corporations (Novo Nordisk A/S and Merck Sharp & Dohme) and PepsiCo among its members. Whether the food and drinks industries will make substantive changes to their products or they are primarily interested in image enhancement remains to be seen.

Question 57

6. Case study: The Framework convention on tobacco control

Answer 57

According to the WHO, there are approximately 1.1 billion users of tobacco around the world in 2019, 80% of whom live in low- and middle-income countries. Tobacco is estimated to kill around 8 million people each year (WHO 2019).

Question 58

6.1 Tobacco use and cancer

Answer 58

The expansion of tobacco use in the first half of the 20th century was significant. A parallel trend was the move away from smokeless tobacco products (chewing tobacco and snuff) to smoking tobacco in the form of cigars, cigarillos and pipes, followed by cigarettes. Initially cigarettes were hand-made, making them labour-intensive and relatively expensive, but with industrialisation and the invention of mechanised ways to produce cigarettes, the market and tobacco consumption patterns were transformed.

Question 59

6.1 Tobacco use and cancer

Answer 59

As figure 4 shows, a rapid rise in cigarette consumption followed suit. In the US, smoking rates were around 47% among males, rising to 66% by the 1940s. In other industrialised countries, a similar trend could be observed.

Question 60

6.1 Tobacco use and cancer

Answer 60

While scientists suspected a link between tobacco use and a range of conditions notably cancer as early as the 18th century, due to small sample sizes and potentially confounding factors such as factory conditions and air pollution, the results of such early studies were deemed inconclusive. A seminal study by Richard Doll and Bradford Hill (1950) offered irrefutable evidence of the causal relationship between tobacco use and cancer. Indeed, smoking causes 80% of all lung cancers that occur in the world.

Question 61

6.1 Tobacco use and cancer

Answer 61

The accumulating weight of scientific evidence may at least in part explain the gradual, but steady decline in smoking prevalence in many established markets (mostly high-income countries) since the 1960s.

Question 62

6.1 Tobacco use and cancer

Answer 62

Figure 5 below describes the rise and fall of smoking trends for men and women aged 35-39 years in the UK, from a peak at over 80% for men and 40% for women in 1950 to 37% for men and 29% for women in the same group by the late 1990s.

Question 63

6.1 Tobacco use and cancer

Answer 63

Tobacco products are highly addictive. Research has found that nicotine is more difficult to give up than heroin. Every year, millions of people try to break the nicotine habit, but only 10% of them succeed. A current trend is worth noting - with the introduction of legislation banning smoking in public places, the use of electronic cigarettes and vaping is on the increase. While some evidence suggests that these are less harmful than smoking cigarettes, further research is needed into the potential negative effects of these products (The Lancet 2019).

Question 64

6.2 Globalisation, Trade Liberalisation and Tobacco

Answer 64

Since the 1980s, ownership of the global tobacco industry has been concentrated in fewer and larger companies as a result of a significant number of mergers and acquisitions. Large tobacco companies have formed through the takeover of smaller companies, leading to the formation of Transnational Tobacco Corporations (TTCs) with operations stretching across the world. According to a report from a US-based NGO Campaign for Tobacco-Free Kids, the largest producer of tobacco products is China National Tobacco Corporation with 42.6% of the global market, followed by Philip Morris International controlling an estimated 14% of the global market, British American Tobacco with 11.8% global market share and Japan Tobacco Inc. with 8.4% of the global market share (Campaign for Tobacco-Free Kids 2018). According to the same report, the cigarette industry is one of the most profitable and deadly industry in the world; cigarette retail values in 2017 were worth nearly USD 700 billion; globally consumption of cigarettes is decreasing in HICs and increasing in LMICs (Campaign for Tobacco-Free Kids 2018).

Question 65

6.2 Globalisation, Trade Liberalisation and Tobacco

Answer 65

Tobacco companies engage in the growth, production, marketing and distribution of tobacco related products. They have benefited from the consistent drive for trade liberalisation via the General Agreement on Tariffs and Trade (GATT) and now the World Trade Organisation (WTO), as well as from regional and bilateral trade agreements, which have facilitated their moves to access new foreign markets at an unprecedented rate. Their size has made them lucrative investors for many governments to try to attract. Their aggressive marketing campaigns equating modernity, female emancipation and sexual liberation with smoking have without a doubt contributed to the increase in tobacco consumption.

Question 66

6.2 Globalisation, Trade Liberalisation and Tobacco

Answer 66

The tobacco industry is infamous for resisting and influencing policy debates and attempts at thwarting policymaking. Collins et al (2002: 267-273) discuss how TTCs have sought to manipulate the policy process to commercial advantage – through moves such as defusing calls for legislation by voluntarily adopting token self-regulation, vetoing proposed legislation, lobbying, litigation, undermining effective control measures upon implementation, infiltrating the policy process by placing industry consultants within the WHO, offering future employment to officials, etc. One major concern has been emerging evidence that the industry has funded science and research to further its vested interests. The most striking example of this is the tobacco industry funding researchers to express doubt and create controversy regarding scientific evidence of the harmful effect of second-hand smoke.

Question 67

6.3 Framework Convention on Tobacco Control

Answer 67

In a world where health risks and opportunities have become globalised, efforts to influence health determinants and outcomes have had to be transferred to the global level, because no state is in a position to address these alone. The transboundary nature of global production and consumption has made it paramount for health policy to be constructed at the global level. The Framework Convention on Tobacco Control (FCTC) adopted in 2003 is a historic global health policy development. While it is not the first international health treaty, it is a milestone for protecting and promoting population health from a global perspective.

Question 68

6.3 Framework Convention on Tobacco Control

Answer 68

The content of the treaty is worth giving some attention to. The main document consists of a broad convention which almost all member states have signed. Its stated purpose is “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke” by enacting a set of universal standards stating the dangers of tobacco and limiting its use in all forms worldwide. To this end, the treaty’s provisions provide minimum requirements that signatories are required to uphold. The core demand-side measures in the FCTC are contained in articles 6-14 - including price, non-price and tax measures to reduce the demand for tobacco. The core supply reduction provisions in the WHO FCTC are contained in articles 15-17 - including issues such as the illicit trade in tobacco products; sales to and by minors, and provision of support for economically viable alternative activities. Within the framework convention, additional protocols can be negotiated, which recognise specific challenges. Currently, there is one Optional Protocol to FCTC adopted in 2012 aimed at eliminating illicit trade in tobacco products.

Question 69

6.3 Framework Convention on Tobacco Control

Answer 69

A framework convention is a specific type of international legal instrument, which sets out broad commitments agreed by the parties, while leaving the setting of specific targets and policies either to individual states or to subsequent agreements by the parties. A framework convention is legally binding on the parties, as much as any international treaty. Broadly speaking, tobacco control measures can be divided into two main types: supply-side and demand-side measures.

Question 70

6.3 Framework Convention on Tobacco Control

Answer 70

Demand-side measures are intended to influence the consumers of tobacco products. Such measures include health education and information, restrictions on marketing activities that seek to influence the consumption of tobacco products, packaging and labelling (including health warnings), minimum age requirements, restrictions on smoking in public places, price measures, and cessation programmes.

Question 71

6.3 Framework Convention on Tobacco Control

Answer 71

Supply-side measures are intended to influence the producers of tobacco products including tobacco leaf farmers, leaf processors, manufacturers and retailers. Such measures include production quotas, crop substitution and diversification, control of contraband or smuggled tobacco products, restrictions under trade policy measures, nationalization/privatization to control ownership of the industry, litigation against tobacco companies, incentives to produce nicotine replacement therapies.

Question 72

6.3 Framework Convention on Tobacco Control Challenges with the Implementation of the FCTC

Answer 72

Having an international convention, while legally binding, is not necessarily a guarantee for political action. It still only establishes commitment and intent, and it is up to the state parties to the convention to then act on these commitments. There has been some criticism of the lack of political will by states to deliver meaningful tobacco control (Munzer 2013; The Lancet 2013). The record of action in compliance with FCTC is decidedly mixed - while some countries have used the FCTC to further propel their national tobacco control programmes into comprehensive policies, others are lagging behind. A good example is point of sale advertising. Thailand is one of the leading lights on tobacco control among low- and middle-income countries, banning point of sale tobacco advertising completely. In contrast, in Sri Lanka, advertising at the point of sale remains very prominent.

Question 73

6.3 Framework Convention on Tobacco Control Challenges with the Implementation of the FCTC

Answer 73

Another measure that has been supported by the FCTC is the use of higher levels of tobacco taxation. Worldwide, evidence suggests that 10% increase in the price of cigarettes will lead to a 4% reduction in consumption in high-income countries, and an 8% decrease in low-income countries. Based on this evidence, WHO has strongly encouraged parties to the FCTC to adopt taxation as a key tobacco control policy measure.

Question 74

6.3 Framework Convention on Tobacco Control Challenges with the Implementation of the FCTC

Answer 74

Warning labels and, in particular, pictorial warnings, have been another example of the transfer of tobacco control policy measures across different countries. Canada was the first country to introduce pictorial warnings in 2001. More than 100 countries have passed legislation requiring pictorial warnings on tobacco products. EU Tobacco Products Directive (2014/40/EU) requires cigarettes, roll-your-own tobacco and waterpipe tobacco to carry combined health warnings consisting of a picture from the EU picture library, a text warning and information on stop smoking services.

Question 75

6.3 Framework Convention on Tobacco Control Challenges with the Implementation of the FCTC

Answer 75

Implementation of the FCTC’s provisions remains an ongoing challenge, especially in low-and middle-income countries, where other public health issues continue to garner higher priority. At the same time, a key outcome of the FCTC that goes beyond the specific content of the convention and protocols is the worldwide political mobilisation of tobacco control advocates which forms the basis of a global movement to tackle a global public health issue. What makes the FCTC extraordinary is the global commitment to an international health policy instrument that is key to addressing at least a part of the noncommunicable disease pandemic. Some analysts have called for the creation of similar legal instruments to address alcohol use ad dietary risk factors – including sugar, salt and saturated and trans fats. Others have argued that industries across these different sectors operate in a different way from the tobacco industry and such measures may not be fruitful. Yet others have proposed that given the varied success of the FCTC in controlling tobacco use, legal instruments may not be capable to address the issues faced by societies. As you can see, debates regarding the most efficient and effective way to address the NCD pandemic are very much ongoing and open. One thing is certain – political action is required sooner rather than later, because the scale of the problem is significant.

Question 76

7. Integrating activity Based on the materials from this session, what, in your view, would be the most feasible, effective policy approach to NCDs (e.g. global/local, individual/structural, legal/economic and so on)? Outline it briefly and provide your reasoning in 2-3 paragraphs in the dedicated discussion forum.

Answer 76

Read and comment on at least two other proposals.

Question 77

8. Summary

Answer 77

This session has covered a significant amount of material, introducing a number of issues and questions for reflection. The focus of discussion has been the problem of noncommunicable diseases, its impact on humanity across countries, the challenges that stand in the way of addressing this problem and the attempts made at international level to develop a common approach to this transnational problem. As discussed, there are four groups of diseases – cardiovascular, cancers, chronic respiratory diseases and diabetes - responsible for the majority of deaths worldwide. These diseases have been associated with a group of four behaviour risk factors – tobacco use, excessive consumption of alcohol, diet and physical inactivity. It is widely argued, therefore, that noncommunicable diseases are preventable. Prevention, however, has proven difficult in practice, compounded by a number of factors – multinational corporate activity, trade liberalisation, economic globalisation. Some analysts have further argued that an approach to preventing NCDs, which focuses entirely on changing individual behaviour is deeply flawed, because behaviour and the causes of NCDs are often determined by structural factors, as well as individual behaviour.

Question 78

8. Summary

Answer 78

There has been significant health policy action aimed at the prevention and treatment of NCDs since the start of the 21st century, illustrated by an extensive number of international, regional and national strategies, action plans, development commitments and even international treaties. Given the scale of the problem, however, some analysts have felt that insufficient commitments to action have been made – including making funding available for prevention programmes, treatment, and further research into NCD risk factors, multimorbidity and medicines. The problem of NCDs is embedded into broader global and societal problems – including poverty, underdevelopment, inequality, access to food and resources, climate change, universal health coverage, and so on, meaning that any solutions to either of these are inevitably complex and interrelated.