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USAID: Standing by on NCD Paul Holmes Washington, DC, USA

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USAID: Standing by on NCD Paul Holmes Washington, DC, USA j VIEWPOINT gOPINION USAID: Standing By on NCD Paul Holmes Washington, DC, USA For more than 50 years, the U.S. Agency for Interna- NCD OCCUR IN HIGHER INCOME COUNTRIES tional Development (USAID) has provided steadfast and AND POPULATIONS generous support and leadership for global health. Unfortunately, such myths persist, even among some ’ USAID s leadership has contributed to dramatic reductions global health professionals. A deeper understanding of in maternal and child deaths, broadened the reach of NCD shows that, rather than diseases of affluence, NCD family planning services, transformed human immunode- are especially diseases of poverty that affect poor countries fi fi ciency virus/acquired immunode ciency syndrome (HIV/ and poorer populations in higher income countries. The AIDS) into a chronic disease, helped to nearly eliminate poor, including those in urban areas, are exposed to a polio, and delivered lifesaving innovations to millions broader range of risk factors, including low-cost and high- worldwide. calorie food, malnutrition, tobacco, limited opportunity for While making many advances on those important exercise, and exposure to environmental pollution. NCD priorities, USAID has largely stood by as the health and tend to affect poor people earlier in life and result in much development costs of noncommunicable diseases (NCD) poorer outcomes. In fact, low- and middle-income coun- mount, undermining its achievements and putting pre- tries are the most impacted, accounting for 80% of all NCD vious U.S. government (USG) investments in global deaths. ’ health at risk. In the USG s 49 priority countries (those The causes of NCD also may be different in those receiving more than US$5 million in health assistance in countries. As an example, whereas infection-related cancers 2013), premature deaths from NCD are approximately are rare in higher income countries, in Africa, they account  1.6 higher than deaths caused by HIV/AIDS, tubercu- for about one-third of all cancers (e.g., cervical, liver, losis, and malaria combined. Yet, USG investments Epstein-Barr, Kaposi sarcoma), and infections cause other addressing NCD in those countries are virtually nonex- NCD (hepatitis, rheumatic heart disease). Further laying lie istent [1]. In 2012, shortly after the United Nations held to the myth that NCD are diseases of affluence, according “ its high-level meeting on NCD, USAID issued its Global to the World Health Organization, the number of obese e ” Health Strategic Framework: FY2012 FY2016 [2], and overweight children in Africa has nearly doubled since “ which recognized NCD as an urgent and growing global 1990 and one-quarter of all obese and overweight children ” “ public health concern and noted that USAID is under 5 years of age live in Africa [2]. Many lower income ” considering how [it] can best leverage existing platforms countries in South Asia and Africa currently face a double to address NCD, but work on advancing that objective burden, where communicable and NCD interact, further seems to have stalled. stressing already underdeveloped and under-resourced People inside and outside of USAID have put forth a health systems. host of reasons and rationales as to why the agency has not stepped up as a global leader on addressing NCD. Several of those reasons, and related misconceptions, are summa- NCD ARE NOT YET AN URGENT GLOBAL PROBLEM The author reports no rized herein, paired with the response and reality per the USAID has consistently characterized NCD as a future relationships that could be NCD community. fl health priority, rather than one impeding global health and construed as a con ict of interest. development and demanding attention today. That From the Department of OUR CURRENT JOB IS NOT DONE perspective was reflected in the Department of State’s Federal Relations—Global USAID’s health programs are led by dedicated world-class USAID’s report “2010 Quadrennial Diplomacy and Health, American Cancer experts who are committed to progress in their particular Development Review (QDDR): Leading Through Civilian Society Cancer Action ” “ Network, Inc., Washington, areas of expertise. From their perspectives, existing health Power. Of NCD, it reads, also, as economic wealth in- DC, USA. Correspondence: priorities present plenty of persistent challenges. Despite creases, chronic conditions such as heart disease, cancer, P. Holmes (paul.holmes@ impressive progress, that perspective holds that when even and diabetes will become more prominent in developing cancer.org). anemia during pregnancy has not been fully addressed, it is countries, demanding stronger links to U.S. expertise to fi ” GLOBAL HEART hard to move on to diabetes and secondhand smoke. So mitigate rising human and nancial costs [3] And the © 2016 World Heart long as women are still dying during childbirth, children same wording was repeated 5 years later in the Quadren- Federation (Geneva). Pub- and adults are still dying from infectious diseases, and nial Diplomacy and Development Review for 2015 [4]. lished by Elsevier Ltd. All millions of couples lack access to modern contraceptives, Previous USAID leadership famously said that we can rights reserved. “ VOL. 11, NO. 4, 2016 other health topics are unwanted distractions that could put the infectious disease era of global health history to ISSN 2211-8160/$36.00. rob attention or precious resources from their incomplete bed.[freeing] up resources for health systems and.that http://dx.doi.org/10.1016/ agendas. next frontier of non-communicable diseases” [5]. Such j.gheart.2016.10.002 GLOBAL HEART, VOL. 11, NO. 4, 2016 425 December 2016: 425-427 j gOPINION statements deny the current urgency of the NCD epidemic, GOOD SOLUTIONS DO NOT EXIST AND NCD ARE unfortunately kick the NCD can down the road, and reflect NOT USAID’S COMPARATIVE ADVANTAGE an institutional inertia or inability to deal with the issue. NCD do present a complex of diseases, interrelationships, fl Such statements also re ect a lack of understanding of causal patterns, risk factors, and approaches for preven- major trends in global health and global mortality and tion, screening, diagnosis, treatment, and care. And most morbidity in 2016. agree that NCD are best addressed in a holistic, multi- sectoral approach. Yet, complexity and challenges are not OUR CURRENT FOCUS WORKS AND IS sufficient reasons to ignore a significant global health and WELL-FUNDED. WHY CHANGE? development concern. Moreover, there is good evidence as Although USAID’s disciplined focus on infectious diseases, to what works well. The World Health Organization and family planning, and maternal and child health has deliv- other agencies have identified a number of NCD ered impressive results and a reliable funding stream with interventions as “best buys,” including control of tobacco bipartisan congressional support, the recent Ebola and Zika and alcohol, vaccinating against human papillomavirus and crises underscore the ever-dynamic face of global health. hepatitis B, screening for hypertension and diabetes, and The core U.S. global health programs and budgets have ramping up awareness and prevention programs. remained largely constant for the past several years. Suc- Just as USAID’s expertise has grown on reproductive cess on existing health priorities notwithstanding, global health and infectious diseases over the decades, so too can health needs change and evolve, and to remain most it grow expertise on NCD. That requires commitment and relevant, USAID’s global health programs must change intentionality. Despite managing US$2.8 billion in global with them. health programs, USAID currently does not have a single employee charged with tracking NCD, which account for CONGRESS SAYS NO! an estimated two-thirds of all global deaths. There is a long-standing perception and apprehension at USAID that Congress does not want USAID to explore any USAID IS CONTRIBUTING IN SOME WAY research or activities connected with NCD or NCD risk Indeed, USAID already is making valuable contributions factors. These perceptions largely derive from years-old that help address NCD. For instance, the agency’s new conversations and historical vestiges of a time when “Vision for Health Systems Strengthening (HSS) USAID struggled for congressional respect and support. It 2015e2019” illustrates USAID’s significant and growing is as if the ghost of Senator Jesse Helms, legendary USAID investments in HSS, which lay a foundation on which opponent and tobacco supporter, still walks the halls at future NCD efforts could be built. USAID’s extensive USAID. Though Congress provides no NCD-specific experience with HIV/AIDS, now a chronic condition, can funding stream, Congress has also imposed no pro- be extended to other chronic diseases. USAID’s emphasis scriptions against addressing NCD risk factors, such as on exclusive breastfeeding and improved nutrition during controlling tobacco exposure during pregnancy, or against the first 1,000 days lowers the risk of NCD later in life. And analyzing the growing impact of NCD on global health and a few pilot efforts are broadening USAID’s understanding development. Recent nongovernmental organizations’ of the relationship between tobacco and secondhand conversations, in fact, suggest growing congressional smoke and neonatal health and the prevalence of NCD interest in addressing NCD. among refugee populations in the Middle East. And with Economic Support Funds, USAID/Jordan is designing a WE DO NOT HAVE THE FUNDING new project focused on NCD prevention, earlier diagnosis,
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