 We're here tonight to have a lively, interactive, conversational exchange on the lead-up to the high-level meeting on NCDs in New York at the UN in September and beyond. We're really meant to sort of look beyond. There has been considerable recent progress, and I'm sure we'll hear from our speakers about much of that progress. The Moscow Ministerial, the WHO analysis, the work that Lancet has done, the work that the NCD Alliance has pioneered, the work that the business community has taken in getting itself organized, and I think it's very important to mention the sort of nascent and building interest that's being shown in many of the major governments within the world, including in our own government. Next week, Michelle Obama will be in South Africa and in Botswana with a big focus on wellness and activity and really it's about talking about the same kind of agenda that she has pioneered here domestically into a setting in Southern Africa. I think that's very promising. I think that's an important signal, and we could cite many other examples from other places in the world where this consciousness is really growing. There are many outstanding challenges and we're going to talk about those challenges today, and we've had a few prior discussions among ourselves about those, and we're defining them in sort of five areas as areas that are going to be enduring challenges that are going to require continued effort. One is defining feasible and achievable targets and goals, and finding a way to make them understandable and integrated with the existing global health agenda. A second piece is leveraging resources and leveraging resources in ways that maybe go outside of our normal expectations. They may be more private-based, they may be coming out of transactions. The whole idea that this is a donor-driven response is different. The model for response and leveraging resources, we're struggling with what kind of response do you begin to engineer? This challenge is occurring in a particularly poignant and difficult moment because of the global budgetary problems and the acute stresses around that and the very crowded agenda and very anxious agenda around global health. The third area is integrating the business sector effectively into solutions. It's a complicated set of interests that come into play. Some are anxious and wary. Others like Medtronic have sort of stepped forward and played a facilitative and catalytic role. A fourth is forming a coherent and durable social movement, and I think that's where the NCD Alliance has been most pivotal in trying to group folks together, define an agenda, create unity and cohesiveness, but it's a tough, tough agenda as many in this room can attest. And fifth is just ensuring high-level political leadership and buy-in. And that's at the head of state, finance minister, media and opinion leaders, and getting this branded and embedded in their consciousness and made part of the dialogue. So we're going to organize our conversation this evening around two core questions. We're going to hear from our speakers. We're going to have a little bit of cross-conversation. We're going to come back to you at each point on those two questions for your comments and questions, and there's a microphone here. Please come forward and do that. I'll just give you a preview of what those questions are going to be. The first, which we'll lead off with momentarily, is what can we realistically expect as the top-line gains from a high-level meeting in September? Let's start with that point. The second question, after we've gone through that one, the second one would be how are we going to manage and navigate the enduring challenges I just outlined, those five enduring challenges? And each we'll have a round of conversation, hear quick answers, come back to you, and then we'll close, at the close, as we approach 9 p.m., we will ask our panelists about what do they think is the single most important thing that needs to happen between now and September to really raise the prospects of success. So by way of introduction, I'm done. So let's move on now to the first question. The first question is, what can we realistically expect as a top-line gains from the high-level meeting in September? And I'm just going to go down to the end of the row here to Trevor and ask our speakers to just quickly give us a couple of top-line points on that. We can do maybe two minutes each, and then we can have a bit of cross-conversation. So, Trevor, lead us all these. Thanks again for seeing us as a leadership on all these issues. It's been a pivotal information sharing point. Thank you very much for that. First of all, awareness, awareness, and awareness. Sound like three points, but in fact, it's just made for emphasis. There's a lot of disinformation, misinformation, lack of information. Having a greater level of awareness, not only at the base of the citizenry, but at the same time, at the level of a minister of finance, minister of economy, aside from the minister of health, is an incredible accomplishment. So we've achieved that goal coming out of September. We've certainly made a leap forward. Cross-government and within-government consensus, coming back to the point on how important it is that various aspects of governments themselves need to be talking with each other. How is it that a healthy environment or the lack of action on NCDs, for example, that may be of concern to the health minister, in fact, should be of great interest also to the minister of economy, who's trying to attract foreign investment into that economy? We don't make it just about health, and that it's talked about across different governments in that same way, but also just simply a framework for action. There's so many people that are, I say, a little bit off-center when it comes to the topic, for a variety of different reasons. And certainly, if we can come out with the foundation of the house being built, whatever you find that to be, whether it be just by getting the terminology right, getting the potential best practices on the table through the meeting, that certainly is a place that we need to start. And then we can talk about the walls and the windows and the colors that you want the walls painted. Thank you. Dr. Reddy. I think in your question, the critical term is realistically. So I will not get into optimistic aspirational statements as to what could happen and should happen. Given the fact that previously, NCVs had not figured on the radar screen of international agencies and most national governments, I think the major gain would be to get the recognition that this is an important global public health challenge. Getting on the radar screen doesn't mean necessarily a smooth landing, or a quick landing. I believe that there would be statements of general intent to confront and control to some extent the NCD epidemic. But the gains I see are sensitization of high level leaders to the need for multi-sectoral policy instruments which they have to coordinate across the government. And also giving them the necessary political will to direct their own health ministries, to reconfigure health services, to accommodate chronic disease prevention and control more effectively. Of course, this is assuming that we do our job well in communicating these messages to them and then get it across. I believe there would be a reaffirmation of the intent for global tobacco control through a better implementation of FCTC. Some reference may be made to other elements like alcohol to availability of essential drugs, but I do not expect to see major commitments coming other than in the area of tobacco control and to some extent management of clinical care services. But where I see the major gain coming in is that it will open the window not only for national action, but for the introduction of NCDs very clearly and unambiguously in the post-2015 revision of the MDGs. Because we would have then put our claim forward and over the next two years if we continue to advocate we will get that in place rather than just have vague statement of communicable and other diseases. So we'll get our place firmly marked by making a success of this particular summit. Thank you very much. Paul. Steve, as you know, excuse me, in Europe and Eurasia more than 90% of all death is related to non-communicable diseases and injuries. So by force, we have been forced to recognize and begin to deal with many of these questions for a number of years. About five years ago we put together the USAID's first assessment of non-communicable diseases. And since then we've undertaken a number of very small but very successful programs dealing with non-communicable diseases in several ways. Things relating to breast cancer and cervical cancer, some road safety work, again, injuries. Some things, we're now looking at what happens to women when they go into a clinic. Are they being checked for and screened for some of the typical non-communicable disease issues? We've done some work on basically dealing with the primary causes of death for women of reproductive age. So even despite all of that, it is really just a beginning. And for us, I would say that that represents my expectations for September. There's been an incredible amount of work that has gone into the high level meeting by a multitude and a broad range of organizations and people. They've offered up lots of suggested outcomes and I'm sure many of those are being talked about in the halls of this conference. Still, we are very much at the beginning. My expectations may seem relatively modest but they would be enormous in advance in the agenda. I'll consider the meeting a success if it accomplishes three things. First, if it demonstrates broad and explicit national and international acknowledgment of the role of NCDs in global health and development. Secondly, if it heightens awareness of global disease patterns in 2011, give us the reality of what the epidemics and epidemiology really is out there. Thirdly, if it recognizes that there are feasible and affordable approaches to NCDs and their prevention and control. Now, echoing Trevor and Srinath, I think these are reasonable and practical and will form a reasonable foundation upon which to build. One thing is very clear. The momentum is substantial and there is no going back. Thank you so much. Johan. Hi, thank you. Yeah, I would echo what Paul just said. I think that the game has changed. I really do and I celebrate. I'm very excited about what's going on. 12 years ago when I first started in global chronic disease, as I mentioned, I thought I'd go to USAID and see if there was interest in this issue and they trotted out Paul because he was the one guy who talked about it. So true. I said, yeah, we have somebody who's concerned about this. I guess apparently now there's two of you or something like that, USAID or something like that. So I think that things have come a long way. I'm very, very excited about this. It doesn't mean that everything doesn't end in September, it just begins. This is a marathon, not a sprint. This is a long-term game that we're in. Other things that I think we need to celebrate and that have already changed are that there's actually NCD alliances in 30 countries, more than 30 countries. That means that in countries like Kenya and Uganda and Denmark and Australia, groups that hadn't necessarily worked together and in some cases been aware of each other, are now coming together as we joke, leave the weapons in the baggage at the door, come in, talk to each other, figure out our shared and common objectives. It's really, really good news. It's amazing. I think it's a lot to be proud of. So even if NCD alliance itself weren't to continue, the momentum is there, it's happening at the country level and NCD alliance is gonna continue. I wanna emphasize that. So there's some things to be really excited about and proud of and then we're starting to see some leadership by a few of the bilaterals. Danita's funding, the Danes are funding some of these NCD alliances in a modest way. And the Norwegians are doing some good things. In terms of realistic goals, things that we can get out of the September meeting, absolutely. FCTC implementation is critical and doable. NCDs in whatever the MDG successor goals also critical gives us some time too. I think time to really get better operations, research and demonstration projects, better evidence and hopefully for the economy to improve somewhat. I think one thing that I learned in the most recent session at World Economic Forum that just occurred now was that the cost of inaction is far in excess of the cost of action. We're finally starting to have some good data that's very important. We'll have more and more of that. We'll have good numbers by September. We heard something along the line. We heard tens of trillions of dollars in terms of foregun income as a result of these diseases. So there's no question that we can make the economic case and that's gonna be important and we'll have better data by September. So, and again, finally, yes, if there's a better understanding publicly of what NCDs are, that's gonna be a really big victory. That would depend, I think, on high-level attendance at the meeting as well. Thanks. Thank you, Peter. I have the disadvantage of being the last speaker and I think my colleagues have covered a lot of the points but I'll bring in a different perspective that having me involved in HIV for the last 25 years, this actually reminds me of what happened in HIV. In the mid-80s, we went through the same thing of trying to get HIV recognized and prevention efforts to start and then the mid-90s is the same thing with treatment. And what is different, though, about NCDs is it took a long time to get recognized but the momentum in the last year or two has been incredible. I mean, when we FHI got involved, I couldn't get anyone to listen to me about NCDs. Now, suddenly, every week, there's a meeting on NCDs and so one of the positive things, even before the September meeting, is the fact that we have achieved some measure of success. On the other hand, it would take a lot more than the momentum that is currently good and here are my expectations, very similar to what my colleagues have mentioned. Global recognition of NCDs, the social, economic and health impact, agency of a global response at all levels, international level, the national level, we still have a lot of work to do at the country level, civil society and the business sectors, political and financial commitment and targets and then finally, country-driven and country-led approaches. We cannot afford the vertical donor-driven approaches. This has to be different. So those will be my expectations for the high level meeting in September. Thank you. Thank you very much. I mean, there's a couple of things that your comments trigger. You're all talking about changing consciousness and using this as a moment of registering the reality and the recognition and that is a sort of fundamental thing. None of you said this is the pivotal historical moment like Ungas in 10 years ago, which I'm very happy to hear that that was not the case because this is a different reality and you're seeing it in those terms. It's interesting that you're saying also that the economic data, the economic burden data is coming forward on top of the epidemiological and demographic data and that will, I think, change the equation, change the calculus around what does this mean and why should we care? And I also hear you saying that around the margins you're starting to see some political leadership beginning to appear around this issue. I'm surprised that you haven't said more about it's got to be demand-driven, it's got to be countries that are really stepping forward and pulling folks on this because they've made the calculation that their future economic growth and society stability depends on addressing this issue. It seems to me that that is one of the key junctures here. I also think that there's many sort of sensible, practical things that could come out of September like eat less salt, eat less fat, exercise more and be less fat, smoke less and drink less alcohol. I mean, there are some messages that have very broad resonance, which could come across that might actually help us in a way in terms of the consciousness in elaborating and maybe you could comment a little bit about, what are the messages that might come out of this meeting in September that have a sort of broad resonance in getting people to acknowledge that there's been the shift and that it really comes back to changes in the way we organize our societies and we organize both our prevention and treatment approaches. Peter? Yeah, in some ways the message is already out but obviously in September this will be highlighted and that there was at the Moscow meeting last month there was some debate as to what actually should constitute NCDs. And I think the consensus was that we should, we need to focus on the limited number of risk factors that's what led to the recognition that this has to be, the NCDs is not going to cover the whole spectrum but it's going to be cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. And the risk factors that are related to these four, the four big ones, as you mentioned, tobacco, which contributes significantly to all three of them, I believe 70% of lung cancer, tobacco contributes to about 70% of lung cancer, 40% of chronic respiratory illnesses and about 10% of CBD. So tobacco has to be the most, and it also has been one of the most successful interventions in industrialized countries. The second one that you mentioned will be dietary behaviors and physical activity. The third one will be alcohol intake and then those three probably will be the three key messages. And I don't think we have to wait until September to recognize these. The difficulty will be getting this translated to the national level, to the community level and also trying to apply the lessons that have been led in industrialized countries in developing country settings. So trying, for example, to buy smoking or increase taxes, they're not work as easily as it is in the developing countries as it's work in a place like the US. And then also, for example, salt reduction in established food industry, that's easy in an industrialized countries in a country where most of the food industries is informal, then that would be a challenge. So there's a lot of research and a lot of new things that we have to try and adapt to a developing country setting. Srinath, Dr. Reddy. Steve, you label this session as a candid conversation. Yes. So let me be contrarian. Eat less salt, eat less sugar, eat less fat. These are public health messages that I've been going around even in low and middle income countries by health professionals. Yes. And these heads of state gathering in the U.M. are not Oprah Winfrey or Dr. Oz. They are not the ones to actually communicate health messages about individual behavior change to people. What we want to really see from them is policy level action. If they can get the food industries to move in altering food processing, if they can actually start modifying some of the tobacco taxation policies, for example, or getting the salt reduced in processed foods and fat substitution, it is those measures that require to be taken. The public messaging has gone on, will go on, it'll go on through the NGO groups that are there, whether it's the Diabetes Foundation or the World Health Federation, all of them with their national member societies will continue to do it. And it needs to come out. But what needs to come out in the U.N. Summit is much more of a policy determination. To address these risk factors. Determination to advance those policies. Not mere health messaging. Yes, Johan. I think, yeah, I would actually agree with what Srinath said. But I think one interesting thing that will happen at the summit actually is it's taking place in a city that's really become a world model for what cities can do around these issues. Cities are the source of part of the problem in terms of people being deprived of choices around food and around physical activity, being in smoky environments. They also are part of the solution and there will actually be some activities, some really interesting activities led by the city itself and by New York Academy of Medicine around showcasing New York City as the host of this event and as an example of what it is that cities can do. I think that's just an important piece to remember in all of this, particularly as we move towards more and more people living in large, sprawling, unplanned cities that help contribute to some of these risk factors. The other piece I think, and I guess it's maybe picking up on something you said was just around donor driven. I think there's a really interesting potential development here where I think a lot of this will actually be middle income country led and it's not about getting outside donor funding, but it is about Srinath's reallocating priorities. I don't know how that will play out. I can't pretend to understand that completely, but I think it's a really interesting way that this is also very different from the Ungas in terms of that it is more the country led by the large new economies that, or has the potential to be over the long term, country led by the large new economies that both are experiencing the burden, but also have access to the solution and are becoming the leading economies worldwide. Paul. I think one of, I would expect one of the key messages that will come out of the Ungas would be the fact that non-communicable disease burden need not be borne entirely by the health sector. The Department of Health and Human Services refers to it as health in all policies. The point being that what we're talking about is not just the responsibility of a clinician or the responsibility of a hospital, it's also the responsibility of the people who plan our cities, the people who put together our tax structures, the people who put together our transportation and grow our food and process our food. It's also the responsibility of individuals and families to take more responsibility for their own individual health and to realize the reality that governments cannot assure my family's health. I need to take responsibility in terms of the choices that I make, the choices that I urge my children and others that I know to make, and basically look out for ourselves. We call it patient empowerment, and I think that's gonna be a theme that's gonna be running through the NCDC. So this is, what I hear all of you saying is this is a fairly complicated case of shared responsibility in which you're looking for governments to embrace this as a matter of national policy and pushing forward. You're looking at businesses and changing their outlook and their approaches and coming to the table, and you're looking at an appeal on individual choice, and that presents a certain amount of challenge in bringing the messaging across and conveying how important this is and how much this is becoming a global concern. In some ways, I don't think it's all that hard though, because our own society is living with this with the consequences in a much more vivid and daily way than if you were to talk about malaria or TB, or it's true also with HIV. I mean, this is something that people can understand in terms of the threat of non-communicable disorders and the need for adjustments on multiple levels to that. Trevor. Still on the outcomes? Yes. Or the main messages? On the main messages. I can't be sure what that final main message is, but I would hope that, if I call it, that the main message exudes an end to blameology. What is blameology? Non-communicable disease is often seen to be a result of poor choices. We know, in fact, that only about a third of non-communicable disease can be changed by changes in diet, changes in physical exercise, and we should obviously prevent the preventable. No question about it, but you've got two thirds that certainly need to be controlled, thought about, and there needs to be a whole spectrum of interventions. Very complicated, but it can be really brought down to one page. So all society, there's got to be all levels, and I certainly hope that the message that governments send is a message of inclusion, a very important report just two days ago about the UN on disability. There's so many people around the world that feel completely excluded from society. I'm not talking just about the lack of a ramp by which they can actually go up and, you know, some stairs, I mean, truly inclusionary in all aspects of the world, and then end to blameology in the context of non-communicable disease control, whatever that may have meant to me. Let me invite our audience to come forward with any comments or questions. At this point on this cycle, we're gonna move in a moment to consideration around how to navigate these major, these five major challenges that I had outlined, but please come forward if you have any questions or comments to add at this point. While we're waiting for that, the approach of this moment in New York, we don't really, you know, most people are not yet poised to really think about this here. I mean, it's not part of our consciousness yet too much at a popular level. What is it gonna take to, in your view, make that change, make that change in terms of connecting to a popular audience that reads the newspaper and then it's going to be, you know, a popular audience that reads the newspaper, that has an interest in foreign affairs, that is, that wants to be convinced that what is gonna happen is important in driving things forward on the global health agenda. Paul, what do you think? Steve, actually the first thing that comes to mind for me is a brand of some sort. We don't have the, you know, the red bow. We don't have any number of different symbols that are out there for different diseases. We have a hard time in the NCD community putting a face on our story. I mean, even the label non-communicable diseases is an amalgamation of, well, we're talking about four but there's another whole world of other diseases and conditions that constitute non-communicable diseases. So we're still struggling with how to put a brand on it, how to make it clear to the average person on the street what we're talking about. Your task, one of your tasks at the Alliance is creating a brand. Creating a brand. Well, and I think, you know, NCDs is for better, you know, that's the term that's come up. What surprises me having lived through the, it's crisis is how many people actually don't even know what HIV stands for anymore, but they know, you know, that's not a positive, but it means that things can kind of become their initials eventually and that's an okay thing. So in terms of the brand, I think that there's general consensus that this is what we've moved towards. In terms of how to shift that consciousness, I think getting, you know, a couple of campaign ideas that are underway, we hope will help with that, but I do think it's gonna be some very high level political leadership and statements and getting a couple of key people to commit to coming to the meeting, getting that out is gonna be really essential. Peter? You went through the whole period of trying to create the consciousness and branding around HIV and now what, as you look back, what do you think? Well, I think I'm going to actually focus on creating a brand at the national level. And even though HIV is known by virtually every adult in most of the developing countries, we sometimes forget. I remember an episode I was in Mozambique several years ago and I was talking to the director of medical services and he asked him whether I was interested in hypertension or cardiovascular diseases and he said actually he went to the USAID mission and asked for some help to help with the stroke cases that most of his wars are filled with and the mission person, this was five years ago said, sorry we don't have enough money for NCDs but if you want to do a program in HIV we'll be happy to support you. And the director of medical services said, I'm the director of health services, not for HIV. The point here is that there's been recognition at the country level for a long time. When I was in medical school 40 years ago, half of the patients in the medical world were stroke cases. Myocardial infection was rare but have diabetes and a lot of those things. So it shouldn't be too difficult to get the recognition that we need at the national level and because people have been dying from these diseases and the same thing happened with HIV. It was the fatality, it was the fact that it was not curable, it was the fact that a lot of people you saw, everybody knew somebody. I was in Zambia, a country office a few weeks ago and I asked the question, how many of you in this room, there are about 60 people in the FHI staff? Other has a relative or a friend who has had a cardiovascular disease and 90% of the people raised their hands. It is the, that's right. Please, please introduce yourself and offer your comment or question. Thank you, my name is Farah Mateen. I'm a PhD student in international health at Johns Hopkins. I'm an adult neurologist by training so I was definitely struck by your comments on stroke. Every time I go abroad to do what we consider to be tropical neurology, I'm overwhelmed by the amount of stroke and head injury and epilepsy that I see. I've been listening to non-communicable disease talks throughout the day and one thing that struck me was that we don't hear very much about non-communicable diseases in adolescents or in children. We tend to believe that non-communicable diseases are only in the aging and the elderly population or at least in older adults. And as a neurologist, I guess, just thinking about epilepsy, again, head injuries, ribopalzy, birth defects that non-communicable diseases are certainly not limited to adults and perhaps that's being overlooked. Thank you. Any of you care to come around this? Add to it type one diabetes, scoliosis, hole in the heart, you name it with a variety of different conditions. Certainly, they could be added to the list and Jerry Anderson at your school has been a tremendously decent spokesperson for these things, right, Srinath? Yes. I mean, so... A romantic heart disease. No, I mean, you go on and on and on, but you're so right. I mean, what else can I do but verify your comments? You're so right. And I think the NCD Alliance has recently come out with some very good pieces on women's health and NCDs, which obviously confronts the mythology surrounding the fact that it's only men, old men, dying of that. And it's certainly about children's health as well, so it's some really jaw-dropping statistics on this. Srinath? Yeah, we have a new publication on children and NCDs that I do together. Well, one of the things that needs to be emphasized is that many of these problems start even in childhood. Not only habits are indoctrinated in childhood, but even biological changes start appearing in childhood. Even there are gene-environmental interactions in which the environment modifies genetic expression, epigenetics. All of that can happen in the womb and in the early childhood. So the fact that NCDs actually have an impact across the lifespan, beginning with childhood adolescence, is something that we ought to really project, because anything happening adversely to children's health or else it's outrage. And like it happened with second-hand smoke hurting children. And now obesity in children is becoming an emotive issue. So I think focusing the impact of NCDs and the causal factors of NCDs on children and adolescents is a useful pathway to take for advocacy. Thank you. Johanna, did you have a chance to complete your thought there? No, no, I just wanted to reference the children and NCDs publication. It's available at the NCD Alliance booth. Thank you. We have some additional comments and questions. Hi, my name is Tui Bui from University of Pittsburgh. I heard some of you said that NCD should be a country-led initiative, and I'm encouraged to hear that. At the same time, I'm concerned that, especially when I'm thinking of low-income countries where they suffer from a double or triple burdens of diseases, both still from communicable and non-communicable diseases, where the reality is that you need donor infusion to combat HIV, AIDS, and communicable diseases. Do you think that ministers and leaders from those countries is going to embrace the NCD without donor infusion to combat NCDs? That's a very fundamental question in terms of is this pattern of response going to be different, not driven by external donors, but driven by demand and leadership in countries? Who wants to take this one? Yeah, very briefly. When we say country-driven or country-led, it does not mean there shouldn't be external funding, but I think that we also have learned enough lessons from a lot of programs, immunization, HIV, that it is important for countries to take the lead, to make sure they recognize they have a problem and start taking steps. The second point is that there are a lot of things countries can do without a lot of funding. Policy issues, tobacco, whether smoking or whether increasing taxes, food industry. There are a lot of things that countries should, the examples that have been given in New York, those are more policy-related rather than funding-related. And the last point is that almost like HIV, CBD or NCDs are multi-sexual approaches. They are not medical interventions. They are interventions that involve agricultural food production. There are a whole group of things that the government our best can deal with this better than donors. Definitely the external funding will be needed, but we need to, at the country level, we need to make sure that we are taking the lead, coordinating, and also making sure that we're getting community involvement, civil society, and the private sector at the country level. Yes, ma'am. Hi, my name is Gretchen Van Vleet. I'm with FHI. My concern is that our entire global health workforce has been very focused on being trained to deal with infectious diseases and communicable diseases. And yet, we're expecting donors and governments to very quickly take up the mantle of non-communicable diseases without necessarily having a trained workforce or even a set of organizations like FHI prepared with a skill set that can be responsive to the kinds of interventions that will be needed. And so, is this something that the Alliance has thought about and that will be addressed during UNGAS? Thank you. We have the training issue. John, you want to lead off, Strenoth? Yeah, in terms of training, yes. Of course, the Alliance is very much thinking about this. The good news is that we are an Alliance of Federations. Federations with some very strong on-the-ground capacity, but there's no question that there needs to be more training of the people that we have on the ground. But we've got the voices on the ground and the people on the ground. Did you have a... As a follow-up, with the era of integration, thinking about training in a different way rather than recognizing or saying that we need a new set of workers, what are the skills that we can provide, the training that we can provide to the workers that we currently have on the ground and that currently work with both the ministry and health departments with NGOs and that kind of thing and thinking about training differently in maybe that more primary care approach. And FHI is already doing that, but I would definitely not... Dr. Reddy. I think you gave the answer yourself in the last phrase when you said primary healthcare approach. I may have. Yes. Well, the bad news is that we are uniformly shot across most low and middle income countries in terms of health workforce overall. The good news is that we do not really require sophisticated approaches. If we actually focus on frontline health workers and mid-level health workers, we can get much done and delivered in terms of NCD prevention and even management. Therefore, strategies should include development of community health workers in a variety of health services delivery, preventive, promotive, and essential primary healthcare. Then even at the level of secondary healthcare, you can get mid-level health workers and what is being called task sharing and task shifting in which you actually multi-skill health workers is possible. Again, getting... You don't need a full-fledged doctor. There are doctor equivalents for three years training. There are specialist nurses who are being trained for this purpose. So we really ought to look at reorientation of our existing health workers along with some re-skilling so that we can actually utilize them much more effectively rather than create huge vertical carters just for this purpose. Paul, you... Could I just wanted to add a word or two about health systems strengthening in general? Clearly, the health systems in most low-income countries are in need of all sorts of assistance even for the communicable disease side and there needs to be a general re-looking at things in order to embrace non-communicable disease in general. But it's the same kind of things. I mean, we can talk about financing or training or medical supplies and equipment. It's the same kind of building blocks, if you will, that can be adapted, tweaked and strengthened to embrace non-communicable disease as well. And I think there's been a dramatic increase in attention on health systems strengthening in the last couple of years that has the potential to begin to unfold a lot of the things that we're talking about. Trevor, I know this training issue's been a big factor in your thinking and metronixing. Can you give the office a comment? Well, I think the nice part of it is that, well, for medical technology companies in any case, training is a huge part of what we do. There's obviously ethical boundaries between the training that we do and then ultimately the sales process. But the nice thing I think about medical technology is that medical technology companies at large is that they often are providing sort of an add-on, if you will, to the training process that is first learned in medical schools. We're not unique that metronixing and doing that. A lot of other companies are involved in that capacity building. And once they've received the training, let's say neurosurgery training to our colleague and the neurologist, they're able to take that training and to do whatever they would like to do with that training. So certainly training up tertiary care doctors of all specialties is key to the business proposition of companies like ours. But at the same time, we're huge contributors to capacity building in a lot of other countries that may or may not have that training already. I pressed. Thank you, sir. Good evening, my name's Walter Strauss. I work in the area of infectious diseases and vaccines at Merck before I'm a surgical company, but I happen to be an adult gastroenterologist by training. I, and I, working in the private sector, I think a lot about how private sector solutions can help address public health problems. And I look back on the situation with HIV in South Africa and recall that a really sentinel moment was when several very large companies, employers in South Africa, realized that HIV AIDS was taking a very significant toll on their workforce. And they really became the catalyst for change in addressing HIV AIDS in South Africa. In the area of non-communical diseases, I think the situation is quite complex. Many of these diseases are diseases that are indolent for a number of years. And I think that the economic consequences of many of these diseases actually fall on disproportionately on older individuals when they may not be, it may be at the tail end of their working careers. So I'm not quite sure that the same economic arguments might play out in the area of having large employers in developing countries take some ownership of non-communical diseases and to be part of the solution. So I wonder what your thoughts are. That's an interesting argument. I mean, we have people living longer. We have aging societies. We have the whole dimension around caring for these populations and the burden that this presents. Who would like to jump in, Paul? Yeah, I'd actually like to take exception to that statement beginning with situation in Europe and Eurasia where we work, people are dying of these diseases or becoming disabled on average of about 20 years earlier than they are in Western Europe. So we are impacting people at the peak of their earning years. And if we look at disability and death for women of reproductive age, we're finding overwhelmingly that it's non-communicable disease and injuries that are killing those women. So from my perspective, and I think that we will talk a little bit more about that earlier, Eric, later, is that if we're really interested in addressing the health and welfare of women of reproductive age and their young children, then per force, we have to look at the things that are really killing and disabling them and impacting the incomes and welfare of their families. Dr. Reddy. It's well known now, as has been said, that in low and middle income countries, a fairly large fraction of deaths due to chronic diseases occur below the age of 70. In India, about 40% of all cardiovascular disease-related deaths occur below the age of 64 years. And that's a major problem. And even those who do not die would have acquired disability because of early events. And this has an impact definitely on productivity, on family fortunes, because family incomes are lost, children's education and nutrition suffers when the wage earner is disabled. So there are cascading effects. It also has an adverse effect not only on the labor market but also on the consumer market. If most of the people are spending their money on expensive cardiac procedures, then they can't buy other goods. So there is an economic impact which is quite adverse in the developing countries. And that is an argument that may not necessarily appear very apparent in societies such as this, but it's clearly a compelling argument in our circumstances. Let's take one more comment question and then we're gonna turn to the second question. Yes, sir? Yeah, I was an early volunteer in the Peace Corps under JFK. And two of our signal doctors at that time were Dr. Schweitzer from Gabon. I don't know what that country is today. And Dr. Dooley in Laos. And I was wondering, and they were very culturally adapted doctors in those environments. And I was wondering what you may have learned from them or what you have done in practicing medicine in the lesser developed countries from the standpoint of culture and ethnic, local medicine, so to speak. Thank you. I think the question there is around, if you're talking about NCDs, is there a particular cultural dimension to this in calibrating the response and how does that play across these different environments? Is that a factor? Yes. Body and soul are one. And how that's defined and how that's carried out in terms of non-committable disease control is very different, right? You know, Asian traditional medicine, African traditional medicine, if it hits the soul, that's obviously gonna have a direct rehabilitative impact upon the patient, mentally, but also then physically. It's not only the advent of medical technologies and pharmaceuticals that are gonna get at that. Just as an example, the founder of our company who lives on Hawaii is very enthused about meditation and very welcoming of Asian best practices. So I don't know that there's a one, obviously you have to have a sensitivity the way in which one attacks is very culturally sensitive and certainly cultural avatars should be welcome. And I think that some may mistake Western companies from sort of having all size, there's one size fits all approach and that's certainly not the case. Let's turn our attention to the whole question around the outstanding challenges and how are we going to manage these enduring challenges? Just to repeat, I mean, we need to be able to define goals and targets in a realistic and clear and feasible way and tie those to the existing agenda in some fashion. Leverage resources in the midst of tough times, integrate the business sector effectively into solutions and overcome the wariness or the hostility and antagonisms, form a coherent and durable social movement out of a complex set of interests. There's a lot less, there's a lot more challenging than what we faced in other settings and really cementing that high level political leadership. So what's this, as you look at this array of challenges that are in front of us, you're making progress, there's no question, there's momentum, things are moving forward. You've got these continued challenges here. Peter, how are we going to navigate our way forward? What's your view on the most effective strategy? Actually, I will take one of those five areas and that is leveraging resources. There was a meeting, an HIV high level meeting, I believe, last week. Currently, $10 billion has been spent a year and they are asking for another $6 billion, so $16 billion a year. And they also project that they would like to have 15 million people on treatment by the year 2015 and that will cost about 24 billion. The point I'm making here is that there is finite resources. And even though we are hopeful that the meeting in September will also generate resources for NCDs, the Lancet NCD Group, I think projects that they will need about $9 billion for the 23 high prevalent countries as far as NCDs are concerned, for three priority interventions, we cannot, it's unlikely that we're going to get a billions of dollars to develop vertical programs. So here, the point here is that how can we leverage the resources that are available? One of the ways is to make sure we are strengthening the health services horizontally to address multiple issues and not only HIV, NCDs and other health issues. The second is to learn to integrate programs, whether it's HIV or chronic diseases like HIV and NCDs or maternal and child health and women's NCD, related NCDs, including the cancers that affect women, or it may be integrating and some of the intersectoral approaches. The third, we also said country-driven and country-led, there has to be national commitments. There are countries, I think Rwanda and Malawi, as far as HIV is concerned, where the external input into their programs is about 90% of their funding for HIV. That can continue to happen. Countries have to make the commitment whether it's budgetary commitments or simply contributing to some of these programs. So we have to find better ways of making sure we are leveraging the resources, not to expect all the resources to come externally. Otherwise, we'll have to wait a long time before we're going to have effective programs that can be skillet enough to make a difference. Johanna. I would just build on that and say, so in one way, we need to change the consciousness of how we work with donors and external funding. I think we also need to change the consciousness of how we work with the private sector. I think civil society needs to really understand that we can work with the private sector in a very meaningful and positive way and to separate out the negative instances from the very positive ways that we can and should and do engage and celebrate the successes that private sector is making in this space as well. Thank you, Paul. Actually, Steve, I'd like to talk about two of your challenges, resources and leadership. And you've already mentioned that this is not the HIV AIDS discussion of 2001. We've got, and people are going to hear this over and over again as things go into lead towards September. It is indeed a very difficult economic environment. And I think we can anticipate the donor countries and not just the United States government, I might add, donor countries in general can be expected to be pretty cautious about any targets that carry with them significant financial contributions and commitments. Most donors are still wrestling with how to recognize and balance NCDs with the existing and still incomplete health agenda. How do they take new priorities while existing priorities already are underfunded? So in that kind of context, at least in my mind, there's several things that begin to point the way forward, at least in thinking for me. First and foremost, we need to make sure that disease prevention, health promotion and patient empowerment are priorities. Whatever we do, it must be cost effective and we need to be able to prove that it's cost effective. We've already talked about health and all policies and those kinds of things. We've already talked about the fact that countries can do a lot without donor assistance and a lot can be done on the basis of information, of awareness, of good offices. So just re-informing that. And countries are going to have to, again, lean heavily on collaboration with foundations, with non-governmental organizations and also with the for-profit private sector. In talking about leadership, I'd like to start actually by echoing Peter's comments on integration. Donors have been very visible and clear about their commitments to the millennium development goals, PEPFAR, GAVI, the Global Health Initiative and the like and it's absolutely imperative to donors that those efforts not be diluted. So part of leveraging leadership on NCDs is being clear that addressing NCDs also advances and accelerates progress on those existing and very visible goals and commitments. We need to show that NCD policies and programs complement rather than divert attention from those priorities and they do. For example, we've seen that increase in incidence of high blood pressure, diabetes and smoking leads to adverse birth outcomes and poor maternal health. We've seen that smoking mothers breastfeed for shorter periods have less milk and their milk is less nutritious. We've seen studies in India that show that approximately half of all TB deaths are related to smoking, particularly amongst men. We've seen studies in Mexico that draw very close correlation between diabetes and TB. We've seen studies in Bangladesh that basically say that if the money that families spend on tobacco were reoriented and diverted to buy food, then literally millions and millions of people would be spared malnutrition and the estimates are that the child mortality due to malnutrition would drop precipitously. So the point being that attention to NCDs can actually accelerate achievement of existing health priorities. Dr. Reddy, what's the best strategy for navigating this current environment, your view? I mean, I would not be presumptuous enough to talk about the best strategy when all the strategies that have been described are very appropriate and very relevant strategies. I'll pick up one from your five challenges and then talk about how it applies to some of the things that have been said before. Among the challenges you listed, forming a coherent and enduring social movement. I think when we're talking about integration, it's not only integration within the health sector, which is very important that we integrate within the health sector with infectious diseases, nutrition and other groups. But many of the determinants of NCDs also have wider implications. They are linked to issues of environment. They are linked to issues of food security. Like for example, tobacco has 4.3 million hectares of arable land devoted to tobacco cultivation, which is totally unpardonable in a world which faces food insecurity. Similarly, when you talk about industrial life, scale livestock breeding, which not only has an impact on red meat consumption for cancers and cardiovascular disease, but produces 50% of the global meat chain and consumes a huge amount of water resources and diverts grain for grain feeding of animals. Similarly, when you're talking about a number of zoonotic diseases, the Institute of Medicine report says that over the last 30, 40 years, there's been a new outbreak every year and 60% of them are zoonotic, animal to human transmitted. And it's not accidental because we are actually increasing livestock breeding on an industrial scale, resulting in not only deforestation, but also building a conveyor belt between wildlife, veterinary population and human population, allowing mutation, migration of his or her confined viruses and vectors. So it is this connectivity to elements of sustainable development, which are of common concern to a much larger segment of humanity that need to be emphasized. And when we build about that kind of a social movement, the number of stakeholders in this would increase. We cannot appear to be sectarian and say that, okay, NCDs have been long marginalized, please give us a space in line today. We have to say, yes, we are important because of the public health dimension, but we share other concerns with you and it's time for us to get together and build a healthier society. So whether it is behavior change among politicians or behavior change among the general public, you need a broader social movement and that social movement has to unite all of these concerns and we have to move from medicine to public health and from public health to sustainable development as the overarching framework. I'd like to invite anyone who care to come forward. Do you have a question or comments? Hi, good evening. Rick Burzon, NIH. I think this is gonna be a much, much, much harder sell than what we did around infectious diseases with HIV and related conditions. There's the economic argument that was made by the gentleman from Merck. There are issues of modeling, I mean, how do you best demonstrate cost-effectiveness through complex work that is not particularly well understood by people in the field to demonstrate that there are cost offsets with respect to trying to demonstrate that there's a good reason to focus on non-comunicable diseases. There are all kinds of issues around doing that. I'm not saying we shouldn't do it, I'm just thinking it through and so what's the glue that holds this kind of initiative together with what we're doing around infectious diseases and it may be just building the capacity around strong primary care and focusing on that as a way of getting at both infectious diseases and non-communicable diseases and that's not gonna be a cakewalk either because there are a number of countries where physicians have a fairly strong base and they may not be particularly happy economically with having mid-levels come in and provide care that they may perceive as being threatening to their profession. I mean, we had that in this country with physician assistants and nurse practitioners, those kinds of issues are taking place now in countries like South Africa. So it's just that it's not that we shouldn't do this, it's just that we ought to go into it with eyes open because it's going to be very challenging to try to shift focus or make a reasonable transition continuing to deal with infectious diseases at the same time, having a hard look at chronic illness and what we can do there to deal with that problem. Thank you. Our speakers like to react to that. I'll just, it's good to see you, Rick. I would just agree with you. More or less it is going to be, it is a complicated process and we are just beginning that process and that venture. There's a lot that we know, there's a lot that we can already apply and do. There's a lot that we can replicate. At the same time, there's a lot that we still have to learn and I'm hoping that information, research, monitoring and evaluation will be a significant part of this overall process. Again, I think it is endemic upon us to be able to demonstrate and provide the evidence for the things and the choices that we ultimately make. Sir. Howard Hu from the University of Michigan. I'm actually an academic and a lot of the portfolio of research of our department is funded by NIH and my apologies to my colleague because actually my remarks are somewhat in contrast to the somewhat pessimistic prognostication of where we can go with this portfolio of ideas about addressing non-communicable disease. Srinath pointed out that in fact, some of the progress in chronic disease will have to do with linking non-communicable disease with the whole idea of sustainability and in fact, although the private sector is here, the private sector that is here are the folks from drug companies, from the folks who are doing the USAID funded work and the private sector that's not here are the industries like manufacturing, like the extraction industries and some of these industries are the very industries that are embracing sustainability and are galloping ahead of governments, are galloping ahead of where the researchers are because they can already see where society is going. Some of our graduates who I chair a department of environmental sciences who are out there as the health and safety officers for corporations are coming back to us and telling us now we've been identified as the chief sustainability officers because our companies understand that even though the United States won't sign on the climate change agreement, it's definitely gonna happen. We're gonna have to do something about carbon emissions and our environmental footprint. And I would say that to actually make progress on non-communicable disease and understand the whole background of things that will contribute towards chronic disease, it's land use for tobacco, it's gonna be how we design our cities. We need to involve that portion of the private sector that's not here, but who are actually gonna be building our cities, who are actually gonna be cultivating our land and who see some of the sustainability future as that may not be something we've been able to do the research because NIH doesn't fund research like that, that has sustainability impacts health, but in fact that is in some way obvious to many of the people who are running our corporations and who are on the ground and seeing in the future where our best strategies will be to improve health, not just non-communicable disease, but health in general. Thank you, thank you very much. Let's have one last comment and then we'll come back to close. Yes, sir. It's always nice to get the last word, okay? My name's Andy Benson. I'm with the International Food Information Council out of Washington, D.C. We're a science-based communications organization that hopes to help to enable public understanding and informed decision. I realize that this is a very, very complex issue. It's multifaceted and we've talked about economics, we've talked about environment, we've talked about policy, we've talked about science, we've talked about sustainability, political leadership. We've also talked about the challenge of branding this issue if I could use your term there and that if we go outside this room even into the street outside and talk to local people about NCDs, they'd wonder what the hell we are talking about. Excuse my French. We're focusing on the complex, we're focusing on stealing and I mean galvanizing political leadership. But I think as we do that, we need to put this into a broader perspective. The one that we've had very little discussion on today is communicating to the publics that we serve, to the stakeholders, to the individuals, to telling them what an NCD is and some very simple messaging on what they can do to help themselves. Now yes, we've got to address all the complex issues but if we spend the next two years doing that and then think afterwards about messaging to the public, a lot of water has gone under the bridge and a lot of opportunity for self-empowerment has passed away and I think our self-empowerment as well as the political world is very important because people, consumers, citizens love to be helped, love to be guided, love to be supported but they hate to be dictated to and anybody in this room who has children who has aspirations to children and I see people suffering from NCDs as children that we hopefully can take care of. If you tell them what to do, are your children likely to do that or to kind of continue doing what they want to do? Even worse, if your children what not to do then they dig in their heels and stick to their guns and say well that's all very well from where you're coming from but I want choice, I'm an individual, this is a democracy, please don't dictate to me. The success is to understand where they're coming from, to help them to do our work diligently and appropriately as a community but to help them understand, to facilitate, to guide and empower them and I think we need to start thinking about that earlier rather than later. Thank you. Thinking about how we can communicate, having some sort of task force on that and... Thank you. ...simple messaging. Thank you very much. Thank you. We're getting to the end of the hour here. I'm going to ask our speakers really to offer us some one single closing thought on what's the most important thing that needs to happen between now and September to sort of raise the prospects of success. Trevor why don't you lead off and then we'll go to Srinath and Paul. Going down the line. Trevor. Plain and simple, we need the heads of state to be present. Manmohan Singh has announced his intent to come. Dilma Rousseff is equally campaigned on the issue of cancer and has said she's going to come. Russia hosted probably the most important meeting coming up. We believe that the Chinese will also come but it has to be truly all heads of state and without all of those heads of state, including one a few blocks down, where we've been obviously encouraging... Try about Canada. We've been encouraging the Misses to bring her husband to the party in September. We need to have all North-South countries, big and small in all sizes. We don't have that degree of attendance. Yeah. The chance for success to manage. Thank you. Srinath. I see success already evolving in the sense that there is a great recognition. This conference itself is symbolic of this. But with specific reference to the UN summit, what we need to do between now and the UN summit, apart from mobilizing the political commitment at the national level so that it is reflected in New York, there's been one glaring problem which has not been adequately addressed. That is the engagement of other UN agencies other than WHO. I must say WHO has been providing leadership to this effort. But a UN summit is wasted if other UN agencies are not constructively and very strongly engaged. Otherwise, you might as well have this meeting in the World Health Assembly. The advantage of multi-sectorality is reflected not only with the heads of state but also with the active engagement of other UN agencies. So these three months, not only we must lobby the politicians back home, but we must lobby the UN agencies, other UN agencies, UNDP, FAO, World Bank, everybody else so that they sync from the same M sheet. Thank you. Paul. Dr. Reddy talked a few minutes ago about working together symbiotically for a better world. And I think that's one of the messages that I want to convey. For me, it's really imperative that we continue the dialogue and discussions to advance NCDs as complimentary to rather than competitive with traditional health assistance. Thank you, John. Get Obama to the meeting and if she can't come, see if her husband's available. Excellent. How will you? Peter, this is your turf here. This is the sovereign state of FHI here this evening. That's right. You get the last word. Simple thing is that for us to diversify the social movement beyond international organizations, get it to the community level, the country level to not to maintain and sustain this beyond, by the summit and beyond the summit. Okay. That was our last word. I want to please join me in thanking our speakers here this evening. Again, I want to thank our sponsors, Kyle Siemens, Ward Cates, and the many other friends from FHI. Thank you very much.