- Becky McCall — United Kingdom
Treating patient earth
With every day comes new evidence of the devastation caused by climate change, and paralleling this rise is the rapid escalation of the global burden of non-communicable diseases. Climate change and non-communicable diseases have an undeniable link—treat one and the other will follow.
The resounding message is loud and clear: act now to protect our climate and planet, because time is rapidly running out. But this call to arms is not the preserve of climate change alone. Similarly, messages and action around non-communicable disease (NCDs) need to adopt a heightened sense of urgency: act now to prevent future disease burden.
In fact, there are multiple parallels between NCDs and climate change, with many of the measures used to prevent NCDs also mitigating the effects of climate change. For example, eating less meat and trans fats to prevent cardiovascular disease and cancers also reduces carbon emissions, while swapping car travel for cycling offers wide-ranging benefits for physical fitness and results in the burning of fewer fossil fuels.
Professor Stefan Swartling Peterson, a professor of Global Transformations for Health at Karolinska Institutet in Sweden, has witnessed the alignment between climate change and human health unfold over the past 30 years. Reflecting on the current pandemic, he says covid-19 has reinforced the link between planetary science and health. “There is a complete alignment between NCDs, climate change and, to an extent, covid-19.”
A foreboding sense of urgency
In 2018, the Intergovernmental Panel on Climate Change (IPCC) published its report detailing the impacts of global warming of 1.5°C above pre-industrial levels. Now, in 2021, we witness the Conference of Parties COP26 summit in Glasgow that aims to accelerate action towards the goals of the Paris Agreement and the UN Framework Convention on Climate Change. Likewise, with NCDs, the urgency is written in the epidemiological data, with these chronic conditions accounting for seven of the world’s top 10 causes of death globally.
Rajesh Vedanthan is an associate professor and director in the Section for Global Health at NYU Grossman School of Medicine. He developed the concept of ‘proactive prevention’ aimed at targeting younger, healthier populations with interventions to prevent NCD risk factors and chronic diseases later in life. “The epidemiological transition is where we see countries with high levels of infectious diseases drop off, while NCDs creep in over time as lifestyles change,” says Dr Vedanthan. “Consequently, the burden of NCDs increases in these populations, most often in low- and middle-income countries (LMICs).” He also highlights that in some countries there remain populations that do not have a significant NCD problem now, but in decades to come will likely develop NCDs.
Crucially, he says changing the narrative on NCDs to one of greater urgency involves disrupting this epidemiological transition. Since most NCDs are significantly associated with lifestyle (even if there is a genetic predisposition), in a similar way to climate change humans need to recognise the importance of the environment—that is, diet, exercise, air quality, stress levels and health checks to name a few. Importantly, we need to acknowledge that individual decisions and choices are constrained by the options that are available.
Harnessing political will on paper
Agendas, treaties and agreements on paper help cement good intentions and retain focus. Because climate change knows no borders, just like NCDs, a lot rests on international as well as national agreements and action. In 2015, the Paris Agreement required heads of governments to commit to lower greenhouse gas emissions and increase renewables such as wind and solar, with the aim of keeping the global temperature increase ideally below 1.5°C. Since Glasgow, however, this goal seems unlikely to be met.
Similarly, efforts have been made by NGOs and international agencies to galvanise political will and commitment towards NCDs. In 2016, the United Nations Sustainable Development Goals (SDGs) set out a vision, with 169 targets to be met by 2030 that strive for a world free from poverty, hunger and disease. Health has a central place in SDG 3. It reads: “Ensure healthy lives and promote wellbeing for all at all ages”, while almost all of the other 16 SDGs are related to health in some way. Of note, the part of SDG 3.4 that relates most directly to NCDs recommends, “by 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and wellbeing.”
In 2018, a UN high-level meeting on NCDs led to a political declaration to meet this target, introducing a ‘5 x 5’ framework used by the World Health Organization (WHO) that includes five sets of diseases (cardiovascular diseases, diabetes, chronic respiratory diseases, cancers and the newly added mental health) caused by five behavioural risk factors (tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity and the newly added air pollution).
For widescale and significant change to happen, political will, combined with effective strategic planning and policy change at international, national and local levels, is essential—whether it applies to strategy around chronic diseases or climate change, or ideally both.
Disrupting early epidemiological trends
Swartling Peterson, who also sits on the NCD Child’s Governance Council, says NCDs in childhood need to be addressed from multiple angles. “It is more than just treating the patient. We need to look at this from a risk factor and a life-course perspective, because risk factors during childhood and adolescence set the individual up for problems in later life.” The global food system is central to the planet’s climate issues. “The food industry says you have the choice, but someone’s choice is dependent on the environment, so we need to modify this so people make the right choices,” Swartling Peterson says.
Changing the narrative on NCDs to one of greater urgency involves disrupting the epidemiological transition
In fact, he notes that by around the age of six or seven a young child can recognise food brands that he or she will eat lifelong. Encouraging children to make healthy food choices during their early years can effectively programme good habits for the next 70 or 80 years of their health, which has flow-on effects for food systems and the health of the planet.
Vedanthan from NYU Grossman School of Medicine also wants to see younger populations prioritised with proactive prevention strategies, especially in LMICs. “We need to disrupt this epidemiological transition with proactive prevention of what almost seems inevitable.” Proactive prevention includes reducing trans fats in processed foods, tobacco taxes, reconfiguring the built environment to encourage physical activity and altering food environments to consciously or sub-consciously increase preference for healthier options. “Ultimately, whichever intervention it is, we ask, does it have impact, does it make a difference and is it possible to do?” Vedanthan says.
Sharing the load
The WHO has an ambitious strategic plan, known as the Triple Billion targets, that by 2023 aims to ensure one billion more people benefit from universal health coverage, are better protected from health emergencies and enjoy better health and wellbeing. The NCD agenda is relevant to all three strategic priorities. Progress towards universal health coverage will increase access to essential services to prevent and treat NCDs; protecting people from the devastating impact of humanitarian emergencies and ensuring the continuity of health services will benefit populations living with NCDs; and promoting health and preventing disease will require intensified action on the major risk factors and underlying social and commercial determinants of NCDs.
I think NCD projects in, for example Rwanda, already demonstrate what countries can do with domestic resources
Adnan Hyder is a professor of global health at the George Washington University Milken Institute School of Public Health in Washington DC. He says we need to shift thinking from long-term to urgent, whether it is NCDs or climate change. He also believes LMICs can lead the agenda to tackle NCD burden rather than wait for large international agencies to come up with a plan. In a similar way to climate change, countries, communities and individuals need to take responsibility and enact change now, as they wait for high-level treaties and commitments.
“We should not wait for leadership to come from Geneva and New York,” Hyder says. “It will be too late. I think NCD projects in, for example, Rwanda, Uganda and Ethiopia already demonstrate what [countries] can do with domestic resources. With more external resources they could do an even better job. “I would like to humbly challenge LMIC governments and say, ‘you have a problem, use whatever resources you have, make a start and show the world what you can do’. Some countries are doing this already; they provide the UN with evidence of success with inexpensively run, domestic programmes, and so they break the cycle of top-down leadership. That’s what we need in global health.”
Ethiopia and Rwanda have taken some novel strides in this area. “Healthcare workers have been trained in doing palliative care for cancer patients, for example,” Hyder says. “Nobody would have thought that palliative care, that is normally hospital-based, could be conducted by healthcare workers.”
Further to the WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS) programme—a standardised method for collecting, analysing and disseminating data on key NCD risk factors in countries—he advocates for the benefits of more regular digital surveys. “In the past few years, we have developed rapid surveys on digital platforms that can be done in days or weeks, to complement household surveys that can only be done every five years or so. And we have shown, in countries like Uganda and Colombia, that these mobile phone surveys gather useful information on NCDs.”
Hyder says it’s also important to remember the commercial or corporate determinants of health when taking on the global and LMIC challenges of NCDs. The tobacco industry is, after many years of hard work, much better controlled in terms of the influence it exerts. “Alcohol, however, has not really been addressed and is strategically exerting influence on governments (such as ministries of health, transport and finance), non-governmental organisations (by funding them) and even academia (by sponsoring research),” Hyder says. He cites recent data from a study in The Lancet showing that for every unit increase in ‘corporate permeation’, implementation of NCD interventions decreased by 5%.
THE ROAD TO SCHOOL Children swimming to school in South Sudan through the contaminated water of the Nile that has flooded the land. PHOTO: Jan Grarup
Driving change through food
Echoing Hyder, Swartling Peterson points out that the commercial pressures of health need more attention because they are central to driving the food systems transition happening across the globe with semi and hyper-processed foods. Similarly, the demands of global food systems contribute to the destruction of our planet and the systems that keep the climate in check.
“The commercialisation of food products is unhealthy for us, particularly for children, and this is driving both the NCD pandemic and climate change,” says Swartling Peterson, who was global chief of health for UNICEF from 2016-20. “If we fix the food system then we will also make a large contribution to reducing further climate change.”
To meet the challenge of human health and planetary health, Swartling Peterson emphasises that we need to join the dots between planetary health activism and human health activism. He is involved in launching a novel concept of sustainable health for people and planet, with the aim of harmonising the two. “Make the Anthropocene [the period of time during which human activities have had an environmental impact on the Earth] more anthropocentric, effectively, and place a different human narrative on climate change. This is where the connectedness between human health and climate change comes in.”
ILLUSTRATION – Luke Best – GRAPHICS – Trine Natskår