Ethical tensions in dealing with noncommunicable diseases globally

Abstract

Noncommunicable diseases pose an increasingly high burden of disease that threatens economic and development, yet cost-effective health interventions exist. World leaders recognized the compelling case for action with the declaration at the United Nations high-level meeting on noncommunicable diseases in September 2011. (1,2) Since that meeting, the World Health Organization (WHO) has been developing a Global Monitoring Framework and the United Nations Secretary-General is preparing to report to the 67th session of the General Assembly in September 2012 on ways to tackle noncommunicable diseases across different sectors. This paper aims to inform these debates by reviewing the declarations that resulted from WHO regional meetings held in preparation for last September's high-level meeting (Table 1). We identified four ethical that must be resolved. These tensions are not exhaustive or mutually exclusive but provide a framework for debate. Human rights approaches Effective action on noncommunicable diseases involves addressing multiple human rights, such as the right to information to make informed choices about diet and activity (e.g. food labels that people can understand), the right to bodily integrity (e.g. freedom from exposure to second-hand smoke); and the right to health (including access to essential medicines). These human rights may conflict with corporate rights, such as the right of pharmaceutical companies to exploit patents or express freedom of speech (through marketing). Human rights language featured much more prominently in United Nations declarations on the human immunodeficiency virus (HIV) than those on noncommunicable disease. The European Region was the only one to argue that Member states need to ... respond effectively and equitably to the health-care needs of people with NCDs [noncommunicable diseases] as part of the fundamental human rights of every human being? There has been no reference to essential medicines in any of the regional declarations, despite evidence of the benefits of cheap generic drugs, such as the polypill. Social Political leaders face difficult decisions about where to invest resources along the causal chain of disease. They must care for those already ill but also tackle the underlying causes of the diseases. Five of the seven regional documents mention the importance of action on determinants. For example, the Brazzaville declaration noted how ... risk factors and the systems put in place to deal with the conditions in which people live are shaped by political, social, behavioural, environmental and economic determinants (4) Others did not use the term social determinants but they were considered implicitly (2) Funding Governments must balance the needs of their own citizens with their obligations to provide aid to other countries. There is a glaring global inequality in the burden of noncommunicable diseases and in the domestic resources available to address them. This raises the basic question of the obligations of rich countries to help poor countries to deal with these diseases. It is difficult to draw on self-interest arguments, such as threats to national security, as has been posed for tackling HIV/AIDS. And, while many health interventions are considered for the global public good, this argument may not be sufficient. There is currently little appetite in rich countries for committing more aid funding. Donors face the dilemma of whether to re-allocate existing funds targeting infectious diseases to noncommunicable diseases. Although these diseases may benefit from a shift from disease-specific programmes to one focused on health systems strengthening, it is difficult to see where resource-poor countries will find funding specifically for action on noncommunicable diseases. All of the regional declarations (except the one made in Nadi which did not address resource issues) (6) argued that noncommunicable diseases should be included in international development goals, although they differed in how this might be supported financially. …