Panelists at Diabetes Question Time

On Tuesday 17 January, C3 Collaborating for Health, Diabetes UK and SilverStar co-hosted a Question Time-style event in Westminster Central Hall, in front of an invited audience of around 150 people. The event was funded by Novo Nordisk. The panel was made up of Grace Vanterpool (a specialist diabetes nurse), three members of parliament – Stephen Dorrell, Keith Vaz and Adrian Sanders – the chief executive of Diabetes UK Baroness Barbara Young, and Viggo Birch, vice-president of Novo Nordisk Europe. It was facilitated by Stephen Dixon of Sky News, and closed with a short presentation from Paul Burstow, minister of state for care services.

The audience was made up of health professionals, policy-makers and others – and both panel and audience included people with type 1 and type 2 diabetes. The event was covered on Twitter (#diabetesqt).

Questions at the event included:

• Will commissioning lead to fragmented care?
• Will the Outcomes Framework work as a catalyst to help people with diabetes or not?
• How can prevention methods be improved?
• How best to care for children with diabetes
• How to encourage sharing of best practice
• The problem of limited access to pumps

Voting at Diabetes Question Time

The audience were actively involved throughout the event. First, all those attending were asked to take part in two votes during the event:

• Will people be more involved in their care in the new system envisaged by the new Bill? (which saw a small majority who felt that people will be more involved)
• Will diabetes care have improved by 2025? (which also saw a ‘yes’ majority).

On arrival, the audience were all invited to participate in a short poll to ascertain views on what should be the top three priorities for the NHS in diabetes, and the results were illustrative of the need to ensure that people with the disease should be closely consulted:

• Among people with diabetes, supporting self-management was seen as the highest priority (40%), followed by identification and prevention (23%), education (23%), and specialist nursing (10%).
• Among those without diabetes, the priorities were different: identification and prevention (43%), reducing variations in access to care and services (23%), and supporting self management (19%).
• Averaged across the audience as a whole, the top three priorities were identification and prevention (37.5%), supporting self-management (25%), and reducing variations in access to care and services (17%).

The lifting of the restrictions on imports in a country with one of the highest rates of obesity in the world (32 per cent of men and 63 per cent  of women are estimated to be obese) was certainly not welcomed by health campaigners. As Samoa’s director general of health, Palanitina Tupuimatagi Toelupe, put it: ‘These are the contradictions we have to face—where health is compromised for the sake of trade and development.’ Another Pacific Island, Tonga, also had to water down proposals to restrict imports on the back of its WTO membership, which confers increased trade and lowered import costs.

The balance between health and trade is a fine one: but is it not time to prioritise health?

Sources: Business Week, 22 November 2011; Taking up the Challenge of NCDs in the Commonwealth: 17 Good-practice Case Studies (C3 and Commonwealth Secretariat), click here >>

There are now some signs that environmentalists and health professionals are beginning to take note of the synergies available in tackling climate change and human health. The Climate and Health Council (here >>) is a network of health professionals interested in this area (around 5,000 of whom, from over 70 countries, have signed a Pledge to protect health and call for a framework to control carbon emissions). The first ever Global Climate and Health Summit Summit (co-organised by the World Federation of Public Health Associations, the Climate and Health Council, Health Care Without Harm and the Nelson R. Mandela School of Medicine at the University of KwaZulu Natal, in partnership with the World Health Organization, the World Medical Association and the International Council of Nurses, among others) is being held on 4 December to coincide with COP17 (more information will be available here >>).

For tweets on health from COP17, follow Climate Health Connect on Twitter (here >>).

The voice of health professionals has been largely silent in the discussions to date, despite the substantial role that the sector can play in reducing carbon emissions – not only by saving money by reducing the environmental footprint of health facilities, but by promoting the clear win–wins for human health when working to mitigate climate change, with many of these potential gains relating to the major risk factors for NCDs:

• Transport is a major contributor to CO₂ emissions. Reducing the number of miles driven – substituting walking and cycling – is an obvious way in which human health could benefit from what appears to be a primarily environmental intervention. This will reduce air pollution (which contributes to the risk of CVD, COPD and lung cancer) and traffic accidents – each of which cause over 1 million deaths a year: mortality in cities with high levels of pollution exceeds that of relatively cleaner cities by 15–20%. And replacing car use with walking and cycling will also work to reduce levels of overweight and obesity.
• Diet also impacts both on our health and the environment. Meat and dairy production currently accounts for about a fifth of greenhouse gas emissions worldwide – and consumption may double by 2050 if current trends continue. Diets that are high in red meat are also unhealthy – consumption of red meat has been linked to many cancers (including bowel and breast cancer), and meat is high in saturated fats, which can contribute to other NCDs such as heart disease.
• Indoor air pollution, largely caused by open fires or traditional stoves, is not only an environmental hazard: it is responsible for around 2 million deaths annually, mostly in developing countries. It increases the risk of acute lower respiratory infections among young children, and is a major risk factor for COPD and lung cancer in adults, especially women. Finding less environmentally damaging options could also save millions of lives.

COP17 represents a huge opportunity that must not be squandered. ‘What is good for the planet is good for health’ is a message that has the potential to be a powerful political lever for policy-makers, bringing home the real impact that climate change will have on many billions of people.

The programme is seeking innovative ideas that bring a new or existing scientific or technological solution to global health issues, either alone or in combination with social innovation (e.g. leadership, the determinants of health, public policy, legal or cultural frameworks) and/or business innovations.

Up to $18 million is available: in the first phase, the organisation will give seed grants of up to $100,000 to develop each concept; beyond that, the innovations with the greatest potential will be eligible for grants of up to $1 million to bring projects to scale. The closing date for applications is 23 March 2012.

Canadian innovators have already benefited from a successful Grand Challenges Canada’s Canadian Rising Stars in Global Health initiative, whose have received seed-grant funding for initiatives including a tattoo that delivers drugs, a wind up foetal heart monitor and technology strategies to support HIV prevention.

Source: Grand Challenges Canada website here >>, 13 November 2011.

The initiative is part of the three-year Primary Diabetes Prevention Project, funded by the World Diabetes Foundation, and is a collaboration between the College of Medicine, the Diabetes Association of Malawi, the Ministry of Health, and the Zodiak Broadcasting Station.

The dual epidemics were highlighted recently at the UN High-level Meeting on NCDs, and this initiative is a novel example of a way in which systems that are currently orientated towards HIV can be extended to include NCDs. As Ambassador Eric Goosby put it at a side-event on ‘Achieving health equity: uniting around a common agenda to address NCDs and HIV’ in New York, ‘[Integration] is smart … and can save an extraordinary amount of resources.’

Source: www.bizcommunity.com, 26 September 2011.

The Declaration is then split into six main headings:

• Responding to the challenge: a whole-of-government and a whole-of-society effort: This focuses on cooperation, leadership and multisectoral effort, and notes that there is a ‘fundamental conflict of interest between the tobacco industry and public health’. It also notes that ‘prevention must be the cornerstone of the global response to NCDs’.
• Reduce risk factors and create health-promoting environments: This focuses on developing and implementing multisectoral policies and interventions focusing on the four major risk factors, including accelearating the implementation of the Framework Convention on Tobacco Control, the WHO Global Strategy on Diet, Physical Activity and Health, and the WHO Global Strategy to Reduce the Harmful Use of Alcohol. It also notes the need to promote healthy foods (including working towards reformulating products, reducing salt and eliminating industrially produced transfats) and to promote and support breastfeeding, as well as increasing access to cancer screening and other medicines to prevent and control NCDs.
• Strengthen national policies and health systems: This calls for the establishment and strengthening of national policies and plans on NCDs by 2013, according to national circumstances, including risk factors, surveillance, treatment and care. Also, it notes the need to take gender-based approaches and to recognise the needs of indigenous people, as well as the importance of universal coverage for poor populations. It also encourages networks to develop new medicines and technologies, particularly learning from HIV/AIDS.
• International cooperation, including collaborative partnerships: Exchange of best practice in health promotion, regulation, technology, medicines etc. is highlighted, and the need for the UN, development banks and other key organisations to work together. It also encourages non-health actors (including, where appropriate, the private sector) to form collaborative partnerships to reduce the risk factors.
• Research and development: Promotion of investment in research on prevention and control of NCDs, including incentivising innovation and using information technology.
• Monitoring and evaluation: Strengthening surveillance at country level is recommended – and it specifically calls on the WHO in collaboration with member states and others, to ‘prepare recommendations for a set of voluntary global targets for the prevention and control of NCDs, before the end of 2012’ and to consider developing national targets and indicators.
• Follow-up: The Secretary General is requested to submit to the General Assembly (by the end of 2012) options for strengthening action through effective partnership, and is also requested to present a report on achievements towards the fulfilment of the Political Declaration, in preparation for a comprehensive review in 2014 of progress made, including impact on achievement of the MDGs.

Not all the ‘asks’ of civil society organisations have been included in the Declaration – it does not, for example, set a target for reducing NCD deaths, which had been called for. But – as is very clear from the section of the Declaration on ‘follow-up’ – the UN HLM is not the end of the process: it is the beginning. Implementing the Political Declaration, and making a real difference on the ground, will be the challenge all UN member states face after 20 September.

Source: Draft Political Declaration of the HLM (click here >> to download – NB it is a large file)

The presidents of the four founder organisations of the NCD Alliance (the International Diabetes Federation, the World Heart Federation, the Union for International Cancer Control and the International Union Against Tuberculosis and Lung Disease) expressed in the letter their ‘grave concern’ that the UNHLM will do little to protect future generations.

The letter click here >> http://bit.ly/nxROf7 has been sent to Ban Ki-moon, the UN Secretary-General, copied to  all the UN Embassies in New York and Geneva, the President and President-Elect of the UN General Assembly and the Director-General of the WHO.

The NCD Alliance is calling on all member states to grasp the once-in-a-generation opportunity afforded by the UNHLM and agree to:

• An overarching goal to reduce preventable deaths from NCDs: 25% by 2025
• A clear timeline for tackling the epidemic of the four major NCDs – cancer, cardiovascular disease, diabetes and chronic respiratory disease
• A set of specific, evidence-based targets and global indicators
• A high-level collaborative initiative of governments and UN agencies with civil society to stimulate and assess progress.

The NCD Alliance has produced a template letter for interested parties to use to lobby their heads of state. The letter in English is downloadable here >> and it is also available on the NCD Alliance website in French and Spanish.

Sources: Financial Times, 18 August 2011; Reuters, 18 August 2011; NCD Alliance press release, 17 August 2011 (click here >>).

The NCD Alliance and others are voicing serious concerns about the progress on the Outcomes Document to date – the latest draft (which is not publicly available) contains no timebound, measurable commitments. There are significant disagreements between member states as to:

• the inclusion of essential medicines and vaccines;
• TRIPS and intellectual property;
• the resources that should be made available to prevent and control NCDs; and
• the processes after the HLM (namely who should report, and to whom, and when).

It is said that there is also opposition to the inclusion of specific action on the risk factors.

As the NCD Alliance noted in a position statement, issued on 10 August: ‘Of particular concern are the actions of the US, Canada and the European Union to block proposals by the Group of G77 (G77) for concrete targets and dates on the prevention and treatment of NCDs and for a global NCD partnership by 2012 to follow up on Summit commitments.’ The Modalities Resolution of December 2010 stated that the ‘high-level meeting will result in a concise action-oriented outcome document’, and it now seems that there is a danger that the eventual Outcomes Document will be too weak to provoke member states into acknowledging and acting on the seriousness of the epidemic.

The delay to negotiations is both a very real concern – that the delay is symptomatic of serious disagreement that could lead to a ‘lowest common denominator’ outcome – but it is also an opportunity for further advocacy of governments. It is essential that the Outcomes Document gives governments worldwide a strong steer on how and where to take action on preventing and managing NCDs, and C3 joins the NCD Alliance in calling on interested parties to lobby their governments. Among the G77 nations this can take the form of calling on them to continue to push for concrete targets, and among EU and North American nations to drop their opposition to many of the most important aspects of the Outcomes Document.

The NCD Alliance website (here >>) and C3’s own pages will continue to report on progress.

It calls on governments to strengthen national policies and health systems to prevent and control NCDs. It calls for multi-sector partnerships (including internationally), better implementation of the FCTC, and specifically calls on the private sector to market responsibly, ensure healthy foods are accessible (including reformulation) and promote workplace health. NCD-related research is also called for, and better monitoring and evaluation.

Source: UN draft Outcomes Document (click here >>), 23 June 2011.

C3 tweeted live from the event – you can see our Twitter stream at www.twitter.com/c3health.

After introductions from the president of the General Assembly and the deputy secretary-general, Ala Alwan of the WHO stated that civil society’s views are essential for informing the High-Level Meeting in September, which will take action on the challenge of NCDs: of the 32 million people who die of NCDs this year, 9 million will be under 60, and 90 per cent of that 9 million will be from developing countries.

The first session, ‘The scale of the challenge’, heard from speakers including Dr Betsy Nabel, Dr Tom Frieden and Professor David Bloom. Professor Bloom’s research into the costs of NCDs are already producing some striking figures – the foregone output due to NCDs between 2005 and 2030 is estimated at a staggering $35 trillion. As he put it, it would be irresponsible to ignore NCDs if you are interested in poverty reduction – and the focus on the link between NCDs and development was a constant theme during the day.

The second session, on the national and local challenges of NCDs, included discussion on the impact of NCDs on the very poorest, and the need for ‘Prevention, prevention, prevention’. And there is no time to waste: as Ruth Colagiuri put it, ‘Start somewhere, start anywhere, start as small as you like – but start now!’ The session heard from around 15 contributors from the floor – there was considerable enthusiam from delegates to have their voices heard, and those who could not be accommodated were encouraged to email their opinions in within the next day or two so that they could be included in the summary document arising from the meeting and the online consultation that preceded it.

The final roundtable was on how to enhance global cooperation (although no mention was made of the uses for social media). Rachel Nugent spoke of the tiny proportion of donor funding (less than 3 per cent) that goes on NCDs – orders of magnitude difference from the trillions of dollars that delegates had been told is being lost to the diseases.

Other themes that recurred throughout during the day were:

• the need to engage with patients, who best know how to deal with the challenges, and make them global champions in the fight against NCDs;
• working across silos, in collaboration not competition with other disease organisations – strengthening health systems benefits all;
• tackling health and health education of children – our generation may have ‘missed the  boat’, but there is much that can be done to protect the health of the young;
• the need for significant improvements in implementing the Framework Convention on Tobacco Control (as one delegate put it, in tight financial times, why are governments not further utilising the revenue potential of tobacco taxes?); and
• multi-sectoral partnership – government cannot do this alone, which is why it is essential for civil society, business and others to come together to face the challenge.

The day closed with a speech from Sir George Alleyne, who called on us to agitate, educate, integrate and communicate on NCDs.

An interesting day – one that was good for reconnecting with old partners and meeting new ones, and one that C3 hopes will feed into the planning for a successful and effective UN High-Level Meeting in September.