Comment

www.thelancet.com Published online May 3, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60728-5 1

Decisive action to end apathy and achieve 25×25 NCD targetsIn 1990, an estimated 26·6 million people worldwide died from non-communicable diseases (NCDs). By 2010, NCDs accounted for 34·5 million deaths (66% of total deaths) globally—the leading cause of death in all regions except sub-Saharan Africa and south Asia, with 28·3 million deaths from cardiovascular and chronic respiratory diseases, cancers, and diabetes.1

The burden of illness NCDs place on individuals, families, and societies is substantial, amounting globally to 1·34 billion disability-adjusted life-years in 2010 (54% of the total), an increase from 1·08 billion in 1990 (43% of the total),2 and disproportionately aff ecting the most vulnerable members of society.3 The economic burden of NCDs is staggering, estimated at US$6·3 trillion in 2010.4 And the health and economic burden is projected to grow, most rapidly in low-income and middle-income countries. No country is spared: health systems in both rich and poor countries are struggling to cope with the growing burden of NCDs.5

The global fi nancial crisis, which has led to society-destroying austerity drives and lingering economic malaise worldwide, means limited fi scal space for signifi cant growth in funding of health systems. Yet well-proven solutions to prevent and control NCDs eff ectively, including in low-resource settings,6 abound. The important risk factors for NCDs have been well documented—poor nutrition (particularly high salt intake), physical inactivity, high glucose, high lipid concentrations, obesity, tobacco use, and excess alcohol use among the most prominent—with robust evidence on cost-eff ective interventions for decisively managing them.7

Europe provides a natural laboratory to witness the benefi ts of eff ective policies for managing risk factors for NCDs and appropriate clinical management (as in many western European countries), and the grave consequences of inaction or failure to implement policies to address risk factors for NCDs (as has been the case in eastern Europe, particularly Russia).8

In 2011, the United Nations General Assembly committed member states to prevention and control of NCDs,9 and at the 2013 World Health Assembly targets were agreed to reduce by 2025 premature mortality from cardiovascular and chronic respiratory diseases, cancers, and diabetes by 25% relative to their 2010 levels—the 25×25 target—with targets for the

risk factors for these NCDs. In The Lancet, Vasilis Kontis and colleagues10 have used comprehensive country data for deaths and risk factors and epidemiological models to analyse the contributions of just six of the modifi able risk factor targets to achieving the 25×25 NCD mortality target. They estimate that achieving the 25×25 targets for these six modifi able risk factors—tobacco use, harmful alcohol use, salt intake, raised blood pressure, raised blood glucose and diabetes, and obesity—would reduce the risk of dying prematurely from the four main NCDs by 22% in men and 19% in women, and delay or prevent 37 million deaths over a 15-year period, including 16 million premature deaths in people aged 30–69 years.10 These are remarkable potential health gains in view of the highly cost-eff ective interventions available, which could be readily scaled up in all countries.

Kontis and colleagues also show that under so-called business-as-usual trends, in which these targets are not reached, there would be 38·8 million deaths in 2025 from the four major NCDs, 10·5 million deaths more than the 28·3 million who died in 2010. Globally, a 50% reduction in prevalence of smoking by 2025, rather than 30%, would reduce premature NCD mortality by more than 24% for men and by 20% for women by 2025.10 Although the fi nancial cost of interventions to address the six major risk factors for NCDs is modest—for example, raising taxes on tobacco, banning tobacco advertising, restricting access to retailed

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alcohol, reducing sugar and salt in food, and providing counselling and drug treatment for people at risk of developing heart attacks and strokes6—the estimated health gains are very substantial. Conversely, the cost of inaction is stunningly high, with millions of avoidable premature deaths that will further widen global health inequities—in 2025, 9·5 million of the 10·5 million additional deaths under the business-as-usual scenario will be in low-income and middle-income countries.10

With the right policy interventions, beyond the substantial health gains from tobacco control there would be substantial societal benefi ts. In most low-income and middle-income countries, tripling excise tax on tobacco would enable a doubling of the infl ation-adjusted price of cigarettes, and reduce tobacco consumption by a third.11

Higher taxes and cigarette prices would achieve greater reductions in tobacco use because cigarette consumption is highly price-elastic.11 Revenue from tax on tobacco could be used to fi nance health systems, especially for the benefi t of vulnerable groups, further increasing health and societal gains. Findings from the Lancet Commission on Investing in Health identifi ed tobacco taxes as the single most important policy intervention for NCD risk factors—and crucial for achieving 25×25 and the grand convergence in health outcomes.12

With political will and leadership, the 25×25 targets are well within reach. But despite robust evidence, well-proven cost-eff ective interventions, and a compelling case for action made by Kontis and colleagues to address risk factors for NCDs to save millions of lives, political apathy prevails. Even with much discourse, meaningful and durable action against NCDs is scarce, with little accountability to achieve the promises made and the targets set at the General Assembly in 2011. Such apathy is shown in the unacceptably low levels of overseas assistance for health allocated for NCDs, which in 2011 was a paltry $377 million, out of a total of about $31 billion of development assistance for health in 2011, despite NCDs accounting for 50% of the disease burden in low-income and middle-income countries.13 None of the innovative fi nancing, which has helped so much to tackle HIV, malaria, tuberculosis, vaccine preventable diseases in children, and more recently maternal health, is targeted at NCDs.14

The challenge of NCDs is less technical than political—25×25 targets can be reached to achieve grand convergence and pave the way for sustainable development. The HIV response and more recently the maternal and child health movement have shown us what is possible when there is political will, global leadership, and a mobilised civil society. The World Health Assembly and the United Nations have the opportunity to drive for coordinated global action and establish independent global and national accountability mechanisms to tackle NCDs. The moment for decisive action has come.

Rifat AtunHarvard School of Public Health, Harvard University, Boston, MA 02115, USAratun@hsph.harvard.edu

I declare that I have no competing interests.

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2 Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life-years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2197–223.

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6 WHO. Package of essential non-communicable (PEN) disease interventions for primary care in low-resource settings. Geneva: World Health Organization, 2010. http://whqlibdoc.who.int/ publications/2010/ 9789241598996_eng.pdf (accessed April 22, 2014).

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9 United Nations. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases, A/66/L.1. Sept 16, 2011. http://www.un.org/ga/search/view_doc.asp?symbol=A/66/L.1 (accessed April 20, 2014).

10 Kontis V, Mathers CD, Rehm J, et al. Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study. Lancet 2014; published online May 3. http://dx.doi.org/10.1016/S0140-6736(14)60616-4.

11 Jha P, Peto R. Global eff ects of smoking, of quitting, and of taxing tobacco. N Engl J Med 2014; 370: 60–68.

12 Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955.

13 Institute for Health Metrics and Evaluation. Financing global health 2013: transition in an age of austerity. Seattle, WA: Institute for Health Metrics and Evaluation, 2014.

14 Atun R, Knaul FM, Akachi Y, Frenk J. Innovative fi nancing for health: what is truly innovative? Lancet 2012; 380: 2044–49.