Do words speak louder than actions? Reflections after the summit.
I deliberately resisted blogging about it for a whole month, partly because I wanted to see the build-up and the aftermath of it, and partly because I wanted to see what everybody else said about it. I am, of course, talking about the UN High Level Meeting for non-communicable diseases (NCDs) on 19th and 20th September. The only other occasion that the UN has met like this on a health issue is for HIV/AIDS. The stakes were and are undoubtedly high and momentum has gathered and continues to gather. Yet there is definitely a sense of anti-climax after the summit. The organisation and run-up to the meeting seems to have been dogged by logistical but more importantly, by blocks through governments and multinational companies concerned about hard outcomes from the meeting.
I followed ex-BMJ editor, Richard Smith’s blog keenly throughout the meeting. It does not seem like the key stakeholders were invited or asked for opinions in time. As he said, probably the best thing to come out of the meeting and the pre-meeting is the NCD Alliance, a robust organisation of all the important stakeholders joined for the common purpose of raising awareness.
There is no question that awareness has been raised, and the summit was covered by medical journals, including the Lancet and the BMJ. Interestingly, the major American journals were notable by their silence on the first NCD summit of its kind. Yet, these same journals are the first to publish trials of expensive therapies for cardiovascular diseases, often with major conflicts of interest. On the subject of conflicts of interest, there are particular concerns about NCDs and the way big company interests are still able to play a major role in the UN.
The newspapers and other press gave coverage, but not as much as one would hope. Some of the loudest calls for actions came from celebrities such as Jamie Oliver. Looking around the WHO website, I did not find much in the way of concrete outcomes.
During my clinical cardiology practice, I have asked doctors and patients in the last few months if they knew that the meeting was happening. Almost without exception the answer was “no”.
On the second day of the summit, Richard Smith depressingly concluded:
“The big failures for me have been the failure to raise understanding of NCDs among the wider population and—as discussed at this morning’s meeting—the failure to recognise the need for a system that has at its centre patients not professionals.” It does not come much more damning than that.
What is the point of global health and health policy if it is not engaging at all with end-users? At the BMA Global Health event last week, I could not help feeling that this is an issue across global health and health policy-makers. Words are important but so are actions, particularly if the global fight against NCDs is to succeed.
The growing global health inequality of new drugs and clinical trials
At the European Cardiology Congress in Paris this week, the news is that cardiovascular medicine is still producing tonnes of new research and there are therapeutic advances in all areas from atrial fibrillation and stroke to heart failure and heart attacks. For example, there are 3 new oral anticoagulants (blood-thinning drugs) which offer true alternatives to warfarin for the first time in 50 years. All these drugs have shown superiority in recent trials presented at this meeting- rivaroxaban in ROCKET-AF, apixaban in ARISTOTLE and dabigatran in the RE-LY trial.
Salim Yusuf, arguably one of the most prolific clinical triallists and lead investigator in two of those trials, also presented the results of a different type of study, published in the Lancet this week. The PURE study included over 150000 patients with known coronary heart disease from 17 countries and showed that even in high-income countries. The drug treatments that such patients should be taking are well-established and available very cheaply-aspirin, beta-blockers, ACE-inhibitors and statins. Depressingly, the proportion of patients globally taking these drugs is less than 50% even in rich countries. In Africa, 80% of eligible patients were taking no drugs at all. As Salim Yusuf said, treatment gaps like this in the HIV/AIDS epidemic led to human rights arguments for broadening of antiretroviral treatment and mobilisation of the global health community and governments.
The inequality was also visible at concurrent “Meet the Triallists” sessions. Delegates clamoured to get to the trial update for the ARISTOTLE trial of the novel anticoagulant, apixaban, but I was one of only 20-30 people who heard Salim Yusuf talk about the PURE trial. Global health cardiology is just not sexy enough yet, even in the wake of the UN high-level meeting in September.
You could argue what is the point of all these fancy new drugs if we are failing to get simple, cheap, proven therapies to the people who need them most, even in rich countries. The tsunami of cardiovascular disease hitting all countries is not going to be touched by all the new drugs currently being trialled. We have to get better at translation. More research funders and senior researchers need to lead new trials with global health impact if we are to have any chance of focusing on problems worth researching.
Obesity: Inequalities in EBM, medical research and policy
Today’s main news story is that obesity is on the up and will continue to rise if coordinated action is not taken at local, national and international levels. A Lancet series of articles examines the evidence for the growing burden and cost of obesity globally and the policy steps needed to prevent 65 million more adults in the USA and 11 million more adults in the UK becoming obese by 2030. Successive governments have allowed the food industry to self-regulate and the evidence clearly suggests that this does not work, since the industry’s interest are profits.
What strikes me is that instructive lessons learned from a strikingly similar case-in-point over the last 60 years, namely the tobacco industry, are not being put into practice. There was good medical evidence for smoking and its detrimental effects of health since the work of Richard Doll and Austin Bradford Hill showed the link with lung cancer in the early 1950s, but it was not until 2005 that the World Health Organization adopted the Framework Convention for Tobacco Control, the world’s first and only public health treaty. Our policymakers smugly talk about tobacco as a tackled problem, but it was less than 10 years ago that UK policy started moving in the direction of smoke-free public places.
We have an obese body of evidence (pun intended) to show that the pathophysiology and epidemiology of obesity is bad for our health, and we have enough evidence to show that current methods of tackling industry problems are not working. Governments are quick to say that the food industry is different but what are the incentives for the food industry to behave differently? Is it going to be acceptable to wait 50-60 years before governments and global health policymakers put evidence into practice? Evidence-based medicine aims, at the end of the day, to institute changes which make the health of individuals better. It seems that there are inequalities in the way evidence is put into practice, based not just on societal interests, but on conflicts of interest, particularly multi-billion dollar industries. If we are serious about EBM and evidence-based policy, we should take lessons learned from other sectors and apply them accordingly.