Tuberculosis and NCDs jostle for space in global health agenda

Attendees test for diabetes at the World Diabetes Day commemoration at uMfolozi Technical Vocational Education and Training College Esikhawini Campus, Uthungulu District in KwaZulu-Natal in South Africa. Photo by: GCIS / CC BY-ND

GENEVA — It is a sensitive moment in the tale of two health issues — tuberculosis and noncommunicable diseases — vying for attention at the World Health Assembly in Geneva this week.

Advocates of both groups are under the spotlight as they prepare for crucial high-level meetings on consecutive days at the United Nations in September. But some fear the competition to inspire heads of state to produce renewed impetus, targets, and money for both causes at the same time is generating a damaging rivalry.

“We’ve got a TB high-level event on September 26 and an NCD [event] on the 27th — what are we saying to the presidents of the world?” one humanitarian advisor told Devex in Switzerland.

“On one day, you are going to hear 1.7 million people are dying of TB — this is the most important infectious diseases problem. And the next day, you are going to hear the data for the number of people with diabetes, heart disease, and cancer … We need to all be working together collaboratively — and that’s what I’m not seeing.”

At a panel event Wednesday designed to emphasize the complementarity between the two, Lucica Ditiu, executive director of the Stop TB Partnership, argued that people being tested for TB had often been referred for HIV tests — but that referrals rarely happened the other way. She feared the same will happen with NCDs.

“I would really challenge the NCD community because I have a feeling that again the TB community tries to run after the NCD [community] to do that and the NCD will push [back], but maybe I’m wrong,” she said.

Given the September meetings come one after the other, Ditiu added that it was important to avoid “confusing people and pulling them in all different directions.”

Sarabjit Chadha, from the International Union Against Tuberculosis and Lung Disease, said the current “fight” he saw taking place between TB and NCD advocates was counterproductive. In the next 10 years, India will have about 100 million cases of diabetes, tripling the risk of TB, he said.

“Even if 5 percent of these patients — because of their immune state — develop TB, it’s a huge burden,” he explained. “If you don’t focus on diabetes enough, TB is going to lose out.”

“I don’t see NCD programs as a threat,” Chadha added, while acknowledging that the more emphasis the World Health Organization puts on NCDs, the more money these issues are likely to attract.

“That may mean less funding for communicable diseases like TB, but I think [NCDs] need that push. I’m not saying the funding for TB should go down — it needs to be increased — but if NCDs are not addressed the effect is that your TB programs are going to suffer.”

Talking NCDs

On June 1, the WHO Independent High-Level Commission on NCDs will issue its report to WHO Director-General Tedros Adhanom Ghebreyesus. The commissioners, including former Chilean President Michelle Bachelet and philanthropist Michael Bloomberg, have the mandate to deliver “bold and at the same time practical recommendations.”

Late last year, advocates told Devex that a “global fund” model was unattainable due to lack of political will, instead favoring domestic resource mobilization. It is thought that overseas development money going toward NCDs has historically been low, but it is also difficult to assess due to the multi-sectoral nature of the issue, with funds not necessarily passing through dedicated envelopes. The Organisation for Economic Co-operation and Development’s Development Assistance Committee, which oversees much official aid spending, is planning to bring in a purpose code to track countries’ NCD contributions.

Tom Frieden, president and CEO of Resolve to Save Lives, an initiative of Vital Strategies, told Devex on Thursday that beating NCDs remains above all, a political question.

“If any government doesn’t take action to control, tobacco, alcohol, trans-fats, excess sodium, and to treat the leading causes of death, they are at some level responsible for the avoidable deaths of their people,” Frieden said.

Tom Frieden spoke to Devex about WHO’s action against trans fats.

The commissioners’ terms of reference call on them to consider “political choices, governance, science and technology innovations, financing for NCDs (both catalytic and domestic resource mobilization), international cooperation, accountability mechanisms, commercial determinants, and modalities for integrating mental health within the NCDs framework.”

On Thursday, WHO member states debated efforts to tackle NCDs, with Italy and the United States among those arguing interventions must be based on sound scientific measures and proven effectiveness.

“The action to be taken must be appropriate and responsive to the social, cultural, economic and health contexts of the individual countries,” the Italian representative said.

“We therefore reiterate that Italy believes that the adoption of fiscal measures on food and their ingredients is an approach whose effectiveness — apart from that for tobacco and spirits — is not sufficiently proven at the moment. Particularly, in the medium and long-term it may lead to dangerous changes in dietary habits, searching for cheaper, less nutritious and sometimes less healthy food.”

Francesco Branca, WHO’s director for nutrition and development, who sits on the commission’s secretariat, told Devex on Thursday that the use of regulatory tools versus voluntary approaches is another point of tension on the commission.

Whereas it is now universally accepted that regulatory tools are appropriate on tobacco, Branca said: “for the diet, this is something which is still not completely agreed.” He said some countries favored voluntary approaches “until proven wrong” for changes on how food is marketed to consumers.

“The use of legislation, regulation, is something that is still a bit controversial,” he said.

WHO ranks the taxation of sugar-sweetened beverages in its second tier of cost-effective steps governments can take against NCDs.

“It is an effective intervention. People have been asking, ‘have you dropped the ball on sugar?’ No, we haven’t. We are just trying to be objective and evidence-based,” Branca said, adding that sugar taxes have only been in place for about the last two years.”

“It’s important that more countries take action and document the actions they take so we’re in a better position to advise other countries on the consequences of this action.”

Under control

Branca said there was no competition for resources between NCDs and TB in the lead up to September, pointing out linkages between nutrition and tobacco.

“TB people get malnourished, but malnourished people get TB more easily,” he said. “Many countries that have been focusing on communicable diseases are now challenged with more and more noncommunicable diseases, so you need a scale-up of health systems to cope with additional challenges.”

The respective directors within WHO say they are relaxed, too. Etienne Krug, WHO director for NCDs, disability, violence, and injury prevention, told Devex he hasn’t detected any competition, either among civil society or within the U.N. health agency itself.

“We had a meeting just last week before the assembly to discuss exactly that: How do we make sure these things are coordinated?” he said. “We have a joint interest in getting as many heads of state as possible to New York for that event, so I’m not concerned.”

Krug added that there are ongoing discussions about the comorbidities between TB and NCDs. “We recognize them more and more and that will also help to show that this kind of competition is not helpful. Personally, I don’t sense it,” he said.

Tereza Kasaeva, who was appointed director of the WHO’s global TB program at the end of last year, pointed out at a side event Wednesday that a high-level conference on TB in Moscow last year included three sessions on links with NCDs. The prominence of NCDs has also attracted other groups, keen to take advantage of the momentum.

Saul Billingsley, executive director of the FIA Foundation, has spent more than a decade working on road safety. Sustainable Development Goal 3.6 calls for a halving of road traffic deaths and injuries by 2020, but Billingsley told Devex the target’s time-frame is too optimistic and not being funded. This week, the foundation called for a U.N. summit on child and adolescent health, aimed at reducing the 227,000 adolescents killed by road traffic and 127,000 killed by air pollution each year.

Billingsley said the foundation decided to lobby on air pollution and NCDs “because we think we’ve probably gone as far as we can with road traffic injury on its own.”

“The NCD community is a powerful ally,” he said. “A lot of what we’re talking about could help their objectives on things like physical activity, so we’re trying to build them in, and work with them as well.”

Ian Caterson from the World Obesity Federation said his organization is also trying to see obesity feature more prominently in the commission report.

“Obesity is a gateway disease because it leads to so many other diseases. You can say you’re going to treat those diseases, but by the time you’ve got there it’s too late,” he said. “Labelling obesity a disease enables both prevention and treatment.”

Caterson worries the NCD commission’s approach is too traditional, rather than looking holistically at “individuals in their society needing to have something done for them.”

But Branca disagreed: “Technically, obesity is an intermediate outcome, so it’s neither a risk factor nor a disease,” the WHO official said. “But we have diabetes as one of the diseases and obesity is immediately connected to diabetes. Also, in the list of targets we have, we have a target on reduction of obesity and diabetes.”

Despite the plethora of events on NCDs in Geneva this week, members of civil society are gearing up for a busy year.

“The NCD battle is not done by any means,” Billingsley said. “They’ve got their commission, they’ve got their high-level meeting. But at the end of the high-level meeting, they are going to have all the same issues that they had before it. So they are going to need some game-changer, some strategy.”

Meanwhile, for TB, “it’s now or never,” Kitty Van Weezenbeek, executive director of KNCV Tuberculosis Foundation, told a panel discussion on Wednesday. She called for the high-level meeting in September to spark the political commitment needed to drive action by countries and technical partners.

“Never, ever before has TB been discussed at the level of heads of state,” she said. “If we cannot convince the world that the biggest infectious disease killer of the world needs the attention, to end TB, I think we are lost.”

For more coverage of NCDs, visit the Taking the Pulse series here.

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    Vince Chadwick

    Vince Chadwick is the Brussels Correspondent for Devex. He covers the EU institutions, member states, and European civil society. A law graduate from Melbourne, Australia, he was social affairs reporter for The Age newspaper, before moving to Europe in 2013. He covered breaking news, the arts and public policy across the continent, including as a reporter and editor at POLITICO Europe.