What are some of the challenges and opportunities in addressing NCDs? Number one is data. When you want to address a problem, one of the first challenges is to find the data which show what the problem is and what works in addressing it. That's almost always a problem in humanitarian action. Evidence is really scarce, but it is particularly so for NCDs, which are difficult to diagnose, and where impact may need to be measured over the longer term. There's clearly a great need for better data. Preferably, including quantitative statistically significant data of large-scale populations in low and middle-income countries. Meanwhile, not all public health action can wait until academically robust data are available. Using the data from high-income countries, some highly plausible parallels can be drawn, and data on baseline populations can be used to infer the situation and emergencies. Finally, smaller scale qualitative studies are very promising, and they can be highly instructive in helping guide action at this point. Number two is related to the awareness of the population concerned. Generalization should be avoided in some affected populations, for example after the earthquake in Pakistan in 2010 and Syrian refugees. NCDs are the top reason for seeking care, and thus it would seem there is a high awareness of the situation. However, in other populations, there seems to be very low awareness of NCDs. For example, one study from the occupied Palestinian territories found that people thought the reason they developed diabetes was sadness, and another, also from OPT, that it was normal to have such a disease and therefore it wasn't much that could be done about it. Many expressed barriers in taking advantage of prevention or treatment in particular, the high cost of drugs as mentioned. For example, one study of OPT shows that only three percent of people over 60 actually purchased the prescribed drugs, since they found them too expensive. Given that diagnosis, for example for cancer, can be difficult and since the symptoms are sometimes diffuse and only develop slowly, both the health service providers and the population may think it's less urgent or important than something like Ebola. So, whereas Ebola can be said to cause disproportional chaos, NCDs in my opinion could be said to cause disproportional complacency. Clearly, there is a need for further awareness raising. Health systems should be responsive to the wishes of populations. But, for NCDs, there may be a great deal of misunderstanding. So, in order for the populations to make a choice, they still need to be better informed. Although, there are genetic factors involved in several of the NCDs, for example South Asian populations are genetically predisposed to diabetes, the things people can do to prevent or live with the diseases require behavioral change away from what may be tempting lifestyles into more exercise, less high calorie or sugary foods, less alcohol, and no tobacco. What so fun about that? So, that might be a barrier. Another challenge is the cost. Treatment of NCDs is very costly. It may cost hundreds of dollars to treat cancer. Public health is always priority-based, how to get the maximum bang for the buck. In an emergency situation, cancer treatment may simply be beyond the financial possibilities, and may consciously be deprioritized. If one makes a parallel with AIDS in the early 1990s, that was also seen as too expensive to treat as prices dropped from $10,000 per year to a $100 per year. It became much more realistic to treat large-scale. For NCDs, several financing approaches may be considered. For example, continuous dialogue with manufacturers to see whether cost can be lowered, especially for large populations. Another possibility would be subsidized pricing. That is not full price but something in between. However, this remains a major challenge and a dilemma. This will also be an issue for the Interagency Health Kits. A standard kits for 10,000 people for three months already costs around $20,000, any additional cost will be a challenge. Another challenge is the complexity. NCDs are generally chronic and therefore, need long-term prevention, treatment, and care. They're often comorbidities among different diseases and disabilities. They may be very demanding of health services in terms of sophistication and referral. This is a great challenge for any system, but particularly for systems devastated by disasters or where the population in need maybe fleeing sometimes through countries where they want to stay under the radar of the authorities and may not seek help. It's also a challenge in terms of integrating with the national health system once the disaster is over, and possibly the additional staff expertise and drugs which were available through the humanitarian action are no longer there. That's again, nothing new. Transiting from the acute phase to longer term development has been a top challenge for the last two, three decades for all of humanitarian assistance, and was still listed as a top priority in the 2016 Humanitarian Summit. But finally, let's also look beyond health. The MDGs contained no mention of NCDs, the SDGs do. That is, NCDs are now a global health priority. But what may be equally important is that there's an acknowledgement of the strong economic aspects. This is both in the for profit production of drugs, but also in the production of the basis for lifestyle risks. For example, food especially sugar, tobacco, and alcohol, but also the increasing awareness of the effect of on the economy of chronic diseases such as NCDs. For example, the World Economic Forum, some years ago listed NCDs as one of the top threats to the global economy. It would perhaps be interesting to see this as an opportunity for bringing attention to the NCDs, rather than only as a threat. One exciting opportunity is the UN high-level meeting, which took place in September 2018. For the first time, this makes reference to NCDs and humanitarian settings. This will provide an excellent platform for future political and practical action.
