Q&A: Grand challenges in chronic diseases

Abdallah S. Daar speaks to SciDev.Net about the Grand Challenges in Chronic Non-communicable Diseases initiative.

Last November Abdallah S. Daar, professor of public health sciences at the University of Toronto, and other leading global health experts launched an initiative identifying 20 grand challenges in chronic non-communicable diseases.

The challenges grew out of a two-year research process that distilled the views of 155 key stakeholders around the planet. The challenges are grouped within six core goals: raising public awareness; enhancing economic, legal and environmental policies; modifying risk factors; engaging businesses and communities; mitigating the health impacts of poverty and urbanisation; and re-orientating health systems.

Here, he tells Priya Shetty why setting these challenges is crucial to galvanising action on chronic non-communicable diseases worldwide.

Both the millennium development goals (MDGs) and the Grand Challenges in Global Health, funded by the Bill and Melinda Gates Foundation, were massive efforts intended to spur progress in improving the health of the world’s poor — why did you feel that a new initiative was necessary?

The Grand Challenges in Global Health programme targeted infectious diseases. It had a different kind of energy behind it and a different kind of process. It also had $450 million behind it. The focus was purely on the needs of the developing world and, in the developing world, almost exclusively on infectious diseases.

There was nothing similar to highlight the grand challenges of addressing chronic non-communicable diseases like heart disease and some cancers. Around the globe, these are now killing more people than infectious diseases. This is the case in most of the developing, as well as the developed, world. Eighty per cent of all the people who die of chronic diseases die in the developing world.

Was it a flaw of the MDG initiative that it didn’t really tackle chronic diseases?

I think it was, but there’s always a danger in being too inclusive in any enterprise. You could lose credibility. People might say "it’s impossible to do everything." Secondly, people start asking about the priorities. In 2000, when the MDGs were set out, the [scale of the problem] of non-communicable diseases was not appreciated, particularly in the developing world. So it might have been difficult [for the organisers] to sell the idea.

But the chronic diseases challenges are fairly ambitious too.

True, but it doesn’t mean that every country will need to do everything at once. Some countries might at first focus on getting basic epidemiological data. Some might need to build up or retool their healthcare infrastructure. All will need to start with educating medical students and other health professionals. So for some of the identified challenges, the priorities might vary for different countries at different stages of development and having different circumstances.

The world’s major donors seem to have tunnel vision that only lets them see the problem of infectious diseases, and not that of non-communicable diseases. Do you agree?

Yes and no. The Bill and Melinda Gates Foundation, for example, has so far been focusing on infectious diseases because that is what they started with. It is also the area where results can be measured faster in terms of reduced morbidity and mortality. Chronic diseases are a more long-term investment.

Nevertheless, the UK’s Medical Research Council, the US National Institutes of Health, the Canadian Institute of Health Research, the Indian Council of Medical Research — all of which are involved in our Grand Challenges Global Partnership — and others, have been funding research into non-communicable diseases such as cancer and heart disease. And there is also a lot of money going into diabetes research and strategies to mitigate the risk of chronic diseases.

More resources have gone into the developed than the developing world, but then some of the issues, unlike with infectious diseases, are common to both. Junk food, smoking, lack of exercise and so on generally have the same effect everywhere in the world. How you intervene may be different. And scaling up interventions, and the whole discipline of implementation research, is something we haven’t taken very seriously so far — and we need to do that soon.

So how do we boost funding for chronic diseases in developing countries?

This grand challenges initiative, and reports such as those from the WHO, the World Bank, and The Lancet, all help to raise awareness. Once our paper was published in Nature, two of our co-authors (Elizabeth G. Nabel, the head of the National Heart, Lung and Blood Institute in the United States, and Richard Smith, the former editor of the British Medical Journal and now head of the Ovations Chronic Disease Initiative), arranged funding for eight new centres of excellence for chronic diseases, seven of which are in the developing world. That’s the kind of outcome you want.

Secondly, the Grand Challenges Global Partnership we have created will encourage research funders to put more money into chronic non-communicable diseases research. It is also helping us think about the needs of those in the developing world and involve the developing world funding agencies, like the councils of medical research in India and South Africa. Among other things, we intend to collaborate among ourselves to reduce duplication, consider joint projects, advocate for measures to address chronic diseases, gather data on research funding, and produce an annual report; and build from there. The Partnership has a secretariat at the Oxford Health Alliance, a UK-based charity tackling the global impact of chronic disease.

Governments in the developing world need to understand the importance of chronic non-communicable diseases — which they haven’t until now. They are always dealing with short-term crises. Last week at the WHO’s general assembly in Geneva, the members accepted a plan that commits the agency to work with the developing world seriously to address chronic non-communicable diseases. The Partnership is hoping to hold a meeting in Geneva in August on how to build capacity to address chronic diseases in developing countries.

Is it that policymakers in developing countries are aware of the problem but don’t know what to do, or are they not as aware as they should be?

It’s a combination. It’s partly having to react to acute crises. It is also that the donor community that supports health care delivery systems are themselves unaware. The donor community plays a key role in health delivery in these countries, and thereby they influence the agendas.

Your recommendations on changing health systems suggest they should become more proactive — focusing on prevention and promoting healthy lifestyles — rather than reactive.

Yes indeed. In any planning you don’t want to react to crises, you want to plan ahead. The planning should take into account the burden of disease in the country. A potential advantage in the developing world is that many countries have such poor healthcare systems that they might find it easier to build, almost from scratch, an integrated system that takes into account both communicable and non-communicable diseases. Countries with well-established health systems, on the other hand, might find it more difficult to retool.

One of the challenges is to ‘engage business’. Does this mean the pharmaceutical industry?

Partly. But the food and beverage industry is more important in this case. For example, children being given sugary drinks and unhealthy snack foods with too much salt and fat contributes significantly to obesity.

In the West, the food and drink industries have come under heavy criticism that is pressuring them to change the way they market products, for example. Has this happened in developing countries?

No, and this brings in the question of regulatory agencies in those countries, and the ability to implement regulations and guidelines. So this isn’t a simple issue. It’s very complex. But you can’t throw your hands up in the air and say it’s too complex. Our paper, for example, could be very helpful to, say, a health minister, who can look at it and ask "what are the entry points for my country?" Once they identify those entry points they can, if they need to, go to experts like those at the WHO and ask for help to implement interventions. They can also approach the donor community with specific implementation ideas.

How many lives could be saved if the world acted on the recommendations from your initiative, and complementary ones from WHO and others?

We could save 36 million lives by 2015. And that’s a pretty conservative estimate.

Abdallah Daar is Co-Director of the McLaughlin-Rotman Centre Program on Life Sciences and Global Health, University Health Network, University of Toronto, Canada.

This article is part of a Spotlight on Tackling chronic diseases.