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Sunday, June 16, 2013

Malignant Neglect: The Failure to Address the Need to Prevent Premature Non-communicable Disease Morbidity and Mortality

Watching a slow-motion disaster unfold is a vexing public-health challenge. It is particularly frustrating when policymakers, aware of the problem, fail to respond. The histories of climate change, HIV, and famine are prominent examples of such malignant neglect—that is, “doing harm by doing nothing.”

The global burden of non-communicable disease (NCD) would, on first brush, not seem to suffer from a lack of policy activity. Recent high-level policy discussions have targeted NCDs. In 2000, ministers from 193 World Health Organization (WHO) member states adopted a Global Strategy for the prevention and control of NCDs at the World Health Assembly [1]. Subsequently, in 2001, the WHO surveyed over 130 member states about their awareness of and response to the high and rising burden of NCDs [2]. Then in 2004, WHO member states affirmed their commitment to addressing diet and physical activity through cost-effective interventions [3],[4]. About one decade later, the United Nations held a High Level Meeting on NCDs at the UN General Assembly, only the second time such a high level meeting occurred for a public health threat (the previous one being on HIV, in 2001) [5]. Over 180 leaders of member states again agreed to implement cost-effective measures to curb the avoidable burden of premature deaths from NCDs, and to address the social and economic consequences of these diseases for households [6]. However, despite these voluntary declarations to act on the avoidable burden of NCDs, the systematic review by Carl Lachat and colleagues in this week's issue of PLOS Medicine reveals that disappointingly little has changed: despite some policy statements, there remains virtually no development of specific policies and programs to address NCDs in the countries facing the highest rates of premature morbidity and mortality. Lachat and colleagues performed a structured analysis of health policies and programs to address diet and physical activity risk factors for NCDs in 116 of the 140 low- and middle-income countries that are WHO members [7]. The authors found that health policies now exist on the books, de jure, in 72% of these countries. However, within the 116 countries NCD prevention programs that address intake of salt, fat, fruit, and vegetable or the promotion of physical activity were found in only 47% (54 countries). A minority of countries have implemented some of the most effective regulatory actions [8],[9]) to address unhealthy diets or measures to encourage physical activity—two risk factors that account for about 40% of the avoidable burden of NCDs. Of these NCD programs, few include a budget, implementation plan, time frame, or statement of which government entity is responsible for making progress toward the declared goal. The majority of programs focus on increasing consumers' awareness of health risks through abstract informational campaigns. There were no policy actions found for counteracting vested interests, including ultra-processed food, alcohol, and tobacco companies, which are driving consumer trends at present. Hence, it was not possible to ascertain whether and the extent to which de jure policies are being met with action on the ground, de facto.

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