 Good afternoon and welcome to CSIS. My name is Catherine Bliss and I'm a deputy director and senior fellow in the Global Health Policy Center here at CSIS. And it's my pleasure to welcome you to the first in a speaker series, a high-level speaker series that we will be hosting over the next few months focused on non-communicable diseases. And as you know, the UN will be convening a high-level summit in September of 2011 to discuss these issues and attempt to share information and share lessons learned and also articulate a set of recommendations and solutions for governments seeking information and working together to address this emerging challenge. We are very fortunate today to have with us to kick off this series Dr. Harvey Feinberg. Dr. Feinberg is the president of the Institute of Medicine here in Washington, D.C. He has been at the Institute of Medicine since 2001 following a number of years as dean, as provost of Harvard and before that dean of the Harvard School of Public Health. And his academic career has focused on the intersection of health policy and medicine in developing countries and in developed countries. So we are very fortunate to have him here today to talk to us about the emerging epidemic of non-communicable disease, the health and policy implications of this transition and what we're witnessing particularly in low and middle income countries. And Dr. Feinberg will discuss the health and policy implications of this disease burden and how the United States is addressing these issues and how it will be able to assist other countries in dealing with this emerging challenge. So before I turn the microphone over to Dr. Feinberg, I want to let you know that we are second event in this series. We'll take place in February on February 16th, so be sure to mark your calendars and plan to attend that session as well. And at that point we will welcome Jean-Luc Batel to speak on tackling the global MCD epidemic, how the private sector can and should be part of the solution. So I'll say a little bit more about that at the end of our session, but let me now invite Dr. Feinberg to address the nascent epidemic, what we know about global non-communicable disease. Thank you. Thank you so much, Katherine, for your kind introduction. It's really a pleasure for me to be with you here at CSIS and especially to have a chance to talk with you about a challenge for global health that is emerging, that is underappreciated, and that is crying out for intense action from the United States and from countries around the world. I think it's very fitting that CSIS has chosen to embark on this series looking at the non-communicable diseases at the time that the world is beginning to focus on this problem in preparation for the WHO summit that Katherine alluded to in September of this coming year. I want to begin my reflections on the problem of non-communicable diseases by taking a step back to global health and what we mean by global health. There are at least five different ways that people think about it. The first is they think of global health as the problems of disease unique to poorer countries in the world. They think of global health as the disease problems unique to the poorer countries of the world. A second meaning of global health is they think of global health as the diseases that are prevalent in poorer countries of the world. That's not the same as the first, and it's especially an important distinction we'll come back to when we think about non-communicable diseases. A third framing of global health is thinking about diseases and health systems comparatively from one country or region to another country or region. So in that context global health could be a north-north comparison developed industrialized countries. It could be a south-south comparison. It could be north-south, but it's essentially framing the problem as a comparative look at health systems and disease problems in different parts of the world. Another way people think about global health is that they think it applies especially to what one might call transnational health problems. Transnational health problems are those problems that you cannot apprehend or deal with from a single country point of view or even from a multitude of individual countries working independently. The problems are interdependent and across all. Problems such as environmental pollutants, for example, or the oceans. You cannot deal with those problems country by country as they impinge on health. And finally, another framing of global health is the notion of global health as public health that is a population health perspective where the population of interest is the entire population of the earth. It is public health with a perspective not of a single community, not of a single country, not of a single region, but global health as public health with a concern about the health of people everywhere. Now, these different definitions are not really mutually exclusive. They're reinforcing, but they illustrate an important backdrop to thinking about noncommunicable diseases. And that is that those who have thought about global health only as the disease problems uniquely situated in poorer countries of the world will necessarily downplay chronic diseases and noncommunicable diseases which are prevalent in wealthy countries of the world. But here is the central fact that I want to leave with you in these few minutes. The central fact is that the burden of disease in poor countries simply because it is greater for communicable disease does not mean it is not also greater for noncommunicable disease. And the facts of the matter are that noncommunicable diseases as a global burden looking at the health of peoples everywhere are predominantly, not just largely, predominantly problems of low and middle income countries. If you look at the total number of deaths from noncommunicable diseases in the world, approximately 80% of those deaths occur in low and middle income countries. 80% of the global deaths from noncommunicable diseases occur in low and middle income countries. If you look at a country like South Asia, like India and Pakistan, for example, together, mortality in those countries from noncommunicable disease is more than twice the mortality from all infectious diseases. And if you look even in sub-Saharan Africa where the burden of HIV aids is so predominant, a country like Nigeria has almost as many deaths from noncommunicable diseases as from all infectious diseases combined. If you ask about particular diseases like diabetes, more than three-quarters of all diabetes-related deaths occur in low and middle income countries. And these diseases are very costly to the economies and to the well-being of those countries. For example, between the years 2005 and 2015, it's been estimated that the three countries of China, India, and Russia may lose between $250 billion of national income just because of the three conditions of heart disease, stroke, and diabetes. Now, I want to draw an important distinction so that we're all thinking about these problems in the same way. Sometimes people associate communicable diseases with acute diseases, and they associate noncommunicable diseases with chronic diseases. Oftentimes, those are accurate associations, but they're not necessarily so. There are communicable diseases which are chronic. Indeed, HIV aids is a very prominent example. Schistosomiasis, many other very prevalent diseases in the world, quite apart from the acute infections of malaria or influenza. And at the same time, you can have a noncommunicable event. You can have a hemorrhagic stroke, which is acute and maybe lethal, but it's not an infectious disease. It's not a communicable disease. But by and large, when we think about the problem and the burden of noncommunicable diseases, we are talking about conditions that have the attribute of chronicity, that linger, that affect people for year after year after year, that produce morbidity, reduction in productivity, as well as illness and premature mortality. So we're dealing with a set of conditions in the world that are more important than recognized, even when you look at it from the perspective of individual countries or of the low and middle income countries as a whole. What is particularly intriguing about the noncommunicable diseases from a global point of view and from an international relationship point of view is the degree to which countries, whether wealthy or poor, share a common interest in preventing and dealing efficiently and relentlessly with these diseases. Do you know that the burden of disease in the world overall projected over the next 10 to 20 years, you know what the leading overall burden of disease is likely to be? It's likely to be psychiatric and neurodegenerative disease and problems like depression, which also affect the lives of young people and take lives prematurely and produce enormous social disruption as we've witnessed in our own country recently in Tucson. These problems of psychiatric illness are prevalent in the world being compounded by the neurogenerative diseases which are accelerating in prevalence because of the aging of the population and represent a very substantial challenge to the world. So the thing to remember so far of what I've said is that these noncommunicable diseases are a serious and even overwhelming problem in the poor countries as well as in the wealthy countries. Now the second point that I want to emphasize is that you can deal with these problems after they occur or you can deal with these problems before they occur. You can adopt strategies that are predominantly about treatment and rehabilitation and management of disease or you can adopt strategies that are about preventing disease, forestalling their development, diminishing their secondary impacts. Of the two, they both have a place but the preventive strategy has the great advantage of when it works producing so much better results because you avoid disease altogether. When it works it saves not just heartache and grief over time but it saves dollars. When it works it has the opportunity to make a difference not just in individual lives but in the lives of communities and whole nations. It can be done. Consider a country like Finland which in the 1960s had one of the highest rates of heart disease in the world. Finland adopted a set of strategies focused mainly on education, improvements in the environment of living and especially bringing together many sectors of society, the health professionals and government working together to help educate the public, change patterns of living. In the 1960s if you visited Finland everybody was buttering their bread. Today the surveys suggest that fewer than 5% are buttering their bread and the effects have been nothing short of astonishing. The mortality rate among working age men from coronary heart disease in Finland has declined by 85% by 2006 compared to just three decades earlier. Now it is true that heart disease has been on the decline in many countries including the United States though it remains a dominating problem. But the results in Finland suggest that concerted action by government health professionals and a public can make remarkable and dramatic differences. So the second point is that these conditions can be confronted by prevention as well as by more effective treatments. And the third point that is very important is that the interventions that are effective in preventing one chronic disease often will have benefit to prevent other chronic disease. The prime example of that of course is tobacco and smoking where when you reduce the burden of tobacco you not only reduce the burden of cancer you reduce the burden of heart disease. When you deal with diet and nutrition and the problem of obesity which is a huge problem in the United States but a prevalent and growing problem elsewhere including in some developing countries. You not only can deal with the reduction in diabetes you can also reduce the burden of joint disease and you can impact also on other chronic diseases and high blood pressure and problems that follow from that. So the third key point is that interventions that can work against one disease can simultaneously have broad benefit across many. And the final point that I want to leave you with is that it is in the vital self-interest of the United States to be actively engaged in the global efforts to reduce non-communicable disease burden. It is true across all diseases but it is especially true for those conditions where we in the U.S. also have a disproportionate burden from these same diseases. So that advances that are made anywhere can be transferred and taken advantage of elsewhere. Lessons that can be learned about prevention and treatment including the testing of interventions for disease at different stages that can be done anywhere in the world can be adapted and used everywhere including in the United States. It is in other words in our enlightened self-interest to be actively engaged in a global effort to reduce the burden of non-communicable disease. I want to just conclude by saying that from the vantage point of the CSIS and others who are now mobilizing including the National Institutes of Health. And I'm so pleased Aaron is here from the National Institute of Heart, Lung and Blood to represent the NIH's efforts in these domains. And we have growing attention in the World Health Organization as evidenced by the program coming in September. You will find if you are interested a brief description of a study about reducing the burden of cardiovascular disease in the world that was conducted at the Institute of Medicine and which will be a part of an ongoing effort to do what we can to help promote more effective interventions in countries around the world. It's something that we can do in other words institutionally, individually and as a society to help promote the reduction of the burden of chronic disease in the world. It's a great venture, it will be a long-term effort, but I for one look forward very much to joining with you and others who will undertake the task. Thank you very much for your attention. I look forward to your comments and questions. Dr. Feinberg, thank you for setting out not just one or two definitions of global health for us, but at least five for us to consider as we think about the emerging challenge of chronic diseases, of non-communicable diseases, and the ways in which countries may be able to work together to articulate both the problems, the extent of the challenge and innovate common solutions both in September and beyond. You've made a very strong case for why the global community both in lower and middle income countries as well as the developed countries needs to work together to address this particular challenge. And I want to start just by picking up on some of the points that you made about the economic challenges associated with non-communicable diseases across the world in developed countries as well as the lower and middle income countries. And we've seen that increasingly lack of productivity and ability to participate in the workplace on a regular basis is something that can be an increasing challenge for communities that are seeing higher rates of diabetes, cardiovascular disease, and other conditions. And I wanted to ask you to say a little bit about the role that you see the private sector playing in addressing this challenge, either in working directly through companies, through workplace programs to improve employee health and working in the community, as well as contributing to some of the global solutions that will be discussed in September and which we'll be working on for years to come. I think there's a really exciting set of forces converging to make it both attractive and compelling for industry, for private business to be directly and actively engaged in efforts to reduce these disease burdens. First, if you set aside for a moment the global aspect of this, just think about domestic issues and domestic needs. If you are a company with a workforce, the advantage you have to a workforce which has reduced absenteeism, reduced cost of health care, and increased satisfaction from a set of programs that promote good health and by their nature prevent the development of diseases, programs that work on nutrition that encourage exercise, that reduce specifically stress in different ways in the workforce, that reward people who give up and who refrain from smoking, that give people ample time for family and child development particularly. When you put these kind of packages together, you've got a healthier, more satisfied, more productive workforce. So companies are discovering this over and over again and there are a number of really exciting examples including a company like Safeway here and nationally, but many others that have really demonstrated how they can encourage a healthier workforce. Then when you move to the truly global companies that have a workforce in many parts of the world, you consider a Walmart. As a prime example, a Walmart that just recently made a policy decision that was publicly announced about changing its entire line of house brand foods to bring them more into line with nutritional guidelines, sound choices for people and families. A very exciting step forward, exciting because it's not just good public relations, it's good business. The fastest growing sectors in many food industries actually are the health food sectors and when you can mainstream these in a dramatic way, the chances are very good that you will do well by doing good as a company. And then when you're a global company and can introduce these policies and practices in your workforce around the world, you not only help the employees themselves but you can serve as a model for what is possible to accomplish in different kinds of settings. And you naturally will adapt the programs that are specific to fit the needs of your workers in different parts of the world, but you have the same goals, you have the same principles, the same kinds of opportunities and it's very exciting. So industry in the first instance working with its own workforce and working both domestically and globally has a very, very significant role. Secondly, as illustrated by the Walmart example and others, there's a lot of good business to be made by promoting healthier products. Because as the public becomes more aware of the choices and wants to make smarter choices for themselves, the companies that will be in a position to meet that need will be the ones who are advantaged. Now you have to set aside and it's a separate issue to talk about tobacco, because there we're dealing with a product that is fundamentally an addictive product. We still have almost one in five of the adult population in the U.S. Still smoking, it's half what it was, but it's a hard core. The remaining smokers on average smoke more cigarettes. And so there's a need for creative thinking about what I would call the third stage strategies around tobacco reduction and elimination which fully confront the addictive nature of the nicotine and the product. So that's a separate issue where private sector contributions in pharmaceutical and other arrangements will also definitely play a part, but which is a separate problem. And then you have the opportunity for business to develop more cost effective value adding technology that can be applied in different parts of the world. If you create in India an EKG measuring machine that is $125 in cost compared to ten times that cost for an equivalent machine in the U.S. And you get that approved. You're going to have a huge market in the United States. It's going to go in that direction as well as opportunity for U.S. and European and Asian companies to develop products that are going to be more successful for chronic disease in their homes. If you develop less invasive models for intervention in advanced cardiovascular disease, there's going to be a huge continuing market for that kind of product. If you create safer, simpler ways of preventing the secondary effects of high blood pressure, you will have another huge global market. So there's going to be tremendous opportunity, there is tremendous opportunity for the private sector to take advantage of these opportunities where the same needs exist in wealthy and in poor countries. So those are some of the things that I would point to immediately where the private sector can be quite directly and successfully involved. Thank you. You've mentioned the issue of exercise and getting people more physically active and also the issue of addiction. And so I'm thinking of getting people addicted to exercise in a way. And last year in March, the Global Health Policy Center along with the Pan American Health and Education Foundation and the U.S. Mexico Chamber of Commerce hosted a session here on the emerging challenge of noncommunicable diseases on the U.S. Mexico border. And one of the key issues that we heard from a number of the speakers was the fact that cities along the border have developed in such a way that people do not feel that they can really get out and exercise. Violence is a concern for people. There aren't parks where they feel comfortable going and that kind of thing. And it really highlighted the importance of bringing the transportation sector, urban planning, the education sector, and others into the conversation. And I wonder if you could say a little bit about the challenges associated with that sort of multi-sectoral approach and what the promises might be, what some of the reasons that we really need to try to bring these groups together. It's a really important point, Catherine, because when it comes to dealing with and especially preventing chronic diseases, the array of interventions and the combinations that you want to put together often, in fact I would say maybe dominantly come from outside the narrowly construed health system. They come from our schools. They come from our design of our communities. They come from our walkways. They come from recreational facilities. They come from the work standards and policies that we were just talking about before. So there is a very, very great need for a health mindset to be available and a part of the thinking of those who don't think of their main interests as having to do with health. And whether that's foreign affairs or it's agriculture or it's the environment or it is education, there's a need to have the dialogue working well enough that all of the leadership in these sectors can envision a way that they can accomplish their goals but do it better in a way that simultaneously advances the health of people individually and of whole communities. So a lot of this especially starts with the way we design our communities. If you design a community where you've got to get in a car to go shopping, you just cannot get there by walking. Well, people are not going to walk to go shopping. So that's not a very smart way we know now to design a community. If you design a community so that you have mixed use available to people that they get out and that there's work and there's recreation and there's social interaction readily available for people. That creates a very different environment than the communities which are isolated and isolating. It creates a different environment for mental health as well as for physical health. When you think about the role of the schools, it's profound. Everything from literally what we teach and how we teach, when we give math problems to children that are word problems, why shouldn't the content of the word problem actually be educational itself? Why shouldn't the content of the word problem also convey relevant messages that are meaningful to the lives of children? When we think about a school environment, what's available in the vending machines can be just as educational as what you're told in the classroom. I was recently visiting the Google campus in California and it's a very interesting company for lots of reasons of course including what you may have heard about the famous cafeterias that they have throughout their campus. I don't know the exact number but there are a lot of them and apparently they've been from the beginning free to the employees. You don't pay to eat and when the then president, he's just announced stepping down, Eric Schmidt was asked why do you give the food away in the cafeterias? His reply was, well why should I pay my employees to pay me for their food? So that was kind of an interesting philosophy. I like that but here's why I'm telling this story. I was on a floor that had a vending machine and the vending machine was the most interesting vending machine I've ever encountered because the pricing on the products in the vending machine had nothing to do with what you would find in the store. It had to do with how unhealthy they were. If you wanted your fats and sugars you could get them but you paid and they had obviously lots of healthy snacks just for the taking. So it was a revelation. So there are lessons we can give in schools, in our workplaces that will also convey the messages and bringing together all of these sectors as you described, the educational sector, the foreign policy sector, the agriculture sector, the community design sector, the architecture community, the people who are involved in building creative education and our educators all have a part in this. Thank you. Let me just pose one more question and then we'll go to, I know there are a number of questions out in the audience as well and we want to get to your insights and suggestions also. I just ask you to reflect a little bit on the nature of partnerships in addressing this challenge and earlier you mentioned before we came in about some of the work that the Institute of Medicine is doing with National Academies in sub-Saharan Africa and elsewhere and that is an example of institute-to-institute kind of partnership. I wonder if you could say a little bit about that and also tell us how you see some of these public-private partnerships playing out with respect to thinking about this as we look towards September of 2011 and then beyond. When we, when you think about the major players now in global health, it's true that the national players are still predominant. There's nothing for HIV really that compares to the President's Emergency Plan for AIDS Relief, PEPFAR in scale, in scope, in its effects, but there's a lot of other players that are very, very important including the non-government organizations and especially the leading foundations, in particular the Gates Foundation, change the whole landscape of the enterprise for global health. What I think is really important in the partnership strategies is to ensure that the recipient country and partner has a dominant voice, not just an equal voice, but a dominant voice in what is actually done. And this is our greatest weakness, I would say, in most of our structured partnerships. It's not allowing a sufficient level of control to reside in the recipient countries. Interestingly, in the PEPFAR program, one of the really intriguing innovations was putting the program in the control of the ambassador in the country, which is a very interesting strategy for encouraging direct leadership-to-leadership coordination in country and to get away from a more sectoral set of divisions. I think that the more broad question about partnerships is a really important strategy for making programs that will have not just temporary success but durable success. And the successful partnership is always going to be, in my mind, one where both parties are gaining. A partnership which has a asymmetrical benefit structure is just not destined to last. And so you need to have both parties or all parties getting something out of it in order for it to be sustainable. And I think if you looked at the whole array of problems in the world and you thought about things like nuclear threat, threat of pandemic disease, threat of non-communicable disease, and aligned all of these threats where there are real opportunities for genuine mutual interest and partnerships that have mutual benefit, those are the ones where I think we've got the most opportunity. And I would certainly include the non-communicable disease in that category. Should we turn to the audience? Yes. So Dr. Feinberg, thank you for answering my question. Let's now turn to our audience. And let me ask you when you are recognized- I'm sorry, it's a little hard to see right here around the podium- to take a microphone and introduce yourself and your affiliation. And please do speak into the microphone so that those who are watching on the web can hear your questions as well. So please, the floor is yours. Thank you, Catherine. Dr. Feinberg, Ward-Kiss-Hells here, thank you for a terrific talk. My question relates to the September meeting of the United Nations General Assembly. What would you like them to do? What do you think they will do? And are you concerned about recent Republican proposals in our Congress this week to decrease funding to the United Nations? Will that impact what the World Health Organization does or can that be circumscribed so that the WHO funding is maintained? It's certainly a concern to me. I'd love to have your thoughts about it. Thank you very much, Dr. Kiss-Hells, for your question. I want to tell you a little story of something that I learned when I was visiting World Health Organization, which I thought was very instructive for me. I was speaking to the senior official there who's responsible for the global response to emergencies generally. And he was describing the time a year before that when they had a visit from a congressman from a Florida district. And before he came, this WHO leader did a little background check on the district. And when the congressman arrived, he showed the congressman a slide which compared the entire budget for the emergency response capacity of the World Health Organization to the budget of the fire department in the county that the congressman represented. And as you could imagine, the fire department's budget was larger than the budget at the World Health Organization. When he got to that slide, which he said was like his second or third slide, the congressman would not let him leave that slide. He kept saying, well, this can't be right. He said this just cannot be the case. That you're protecting the entire world for less money than I have available in our fire department in the county. And of course, the answer was that's the situation. Now fundamentally, when you look at the task that the world has assigned to the World Health Organization, and not to mention the UN more broadly, and you compare that to the resources that have been made available to execute on that assignment, the discrepancy is stark and very, very dangerous. And so survey after survey of the American public reveals that people want to give money for effective programs overseas. They believe that the U.S. must be donating 10% of its federal budget to foreign assistance, when of course it's, you know, a hundredth of that. And so we are in a situation where public appreciation of the need and public perception of what we're actually doing is discordant from what the public would actually support and want to do if it could know the facts. And so I believe it's incumbent on members of the congress who are leaders and of the leadership in our executive branch to do their best to ensure that the facts are known, that the needs are known. Now all of this of course goes without saying that we need to have adequate controls and accountability over the way any funds are expended on behalf of the public good. And it applies to us domestically as it would apply to our international agencies. But that's not really the central problem. In my mind the central problem is that we simply have underfunded and over asked what we expect from our global agencies and that's not a good recipe for success. Please, we'll take one and then the next here at the center table. Aaron Chokalanga from Nation Heartland and Blood Institute. Dr. Feinberg, thank you for that fine talk and for your wisdom. I think I couldn't be more happy with any emphasis on prevention. Now the UN summit is happening in the next six months and everybody is getting ready for it and every heads of state, every minister of health, every minister of finance is confronted with the issue of how to tackle with the health burden in every country. Under these circumstances, when the chronic disease is going to be discussed, of course there will be more attention towards it. Now in terms of prevention, when countries are spending anywhere between 15 to 75 to 100 dollars per year per person in most countries, much of the funds will be devoted towards curative diseases. Now what will be your advice to these heads of states who are going to be coming in a few months to put some of those funds towards prevention? Because there's always a competition for funding and prevention doesn't get any funding at all. Yes, well thank you very much for the comment and the question. I think it's in fairness the underfunding of prevention is not exclusively a problem of the developing world. We in the United States also do not give adequate funding relative to its potential return, relative to its value for health to prevention. There are many reasons for this, one of which is the compelling character of treatment and the high cost of treatment which tends to take away these resources. I would say that one of the great advantages of the UN gathering is it will bring the ministers of finance as well as the ministers of health to the table. One of the great difficulties in dealing with these problems of non-communicable disease or any disease in fact is that it has to begin with budgetary realities and work through the overall finance. I believe that the world can benefit from the example of countries that have succeeded and learn from their example. You could take the example of Finland, take North Korea example, take other examples like Costa Rica, take countries which relative to their wealth have done extremely well in prevention of disease and the longevity of their population, the limitation of infant mortality and have succeeded for less doing more. And that's I think going to be a very important starting point of the discussion, learn from the examples that have already been accomplished. And then secondly I think that we can't just talk about these strategies in the abstract. We have to be able to come forward with very concrete program proposals that a minister of finance can examine in context of their national priorities and understand what it would cost and what the likely benefits and when will they know and have the monitoring and surveillance in place to demonstrate whether it worked or not. And whether it exceeded its expectations or fell short. But we need to have concrete plans. And finally I do think that we need to have a concerted global financial support to encourage and reinforce and to help underwrite the cost of the threshold for prevention, getting over the threshold because once you get over that threshold the value of the returns will be evident. But you have to be able to get over that initial threshold. And there's where I think especially global collaboration and funding can be important. So those are a few things that I would stress. Thank you. Yes we have another question here at the center table please. Ed Berger the Eurasian medical education program of the American College of Physicians. Let me touch a focus on one of the issues that you have touched on tangentially. As one who's been in the trenches for the last two decades on these matters. One of the observations that is undoubted has been the political momentum that has been very strongly skewed towards infectious diseases. And that has directed the courses and sources of money as well. I would propose that we ought to think about making the case that it is not an either or proposition but in fact a balance that ought to be struck in behalf of the global burden of disease. The burden of cardiovascular disease has such an enormous effect on the demography, the demographic trends in certain parts of the world at this point to the extent that they will not in fact be altered without doing something about non-communicable disease. But it's that political balance that has been so telling and so influential that has kept non-communicable disease off the table to a great extent. Well thank you very much for your comment Dr. Berger. Appreciate it. Let's see. Let's go to the back. We had a couple of questions. Someone has been very patient back here. I think our mic is not quite available in the back. So let me go over here to the gentleman in the tan coat. Thank you. I'm Leon. Wineshaw University of Wisconsin Washington Semester in International Affairs. I'd like to ask you about one of the figures you mentioned early on about I think you said 80% of the non-communicable diseases occur in third world and middle income countries. You stated that as a cause of concern. Now as far as I know, in fact the majority of the world's population is in fact in those countries so perhaps it's not all that alarming if it's out of proportion. And in responding to that I wonder if you could also share with us your knowledge of overall death rates in third world developing countries as far as non-communicable and communicable diseases and how they might compare with middle income or developed countries. Those are very, very good questions. The point that I was making was that 80% of the deaths from the non-communicable diseases occur in low and middle income countries and your point is a very valid one. If 80% of the deaths occur there but 85% of the population lives there then actually proportionately it's fewer deaths as a fraction of the world's population. The point though is when you do look at the rates per thousand of population in the United States we have approximately 800 deaths per 100,000 people per year just in round numbers. There are countries that have 10 times that and in countries that have 5 or 10 times that if the rate of death from communicable disease per 100,000 population will greatly exceed the rate of the same diseases per population in the United States. So what I can tell you is that the non-communicable disease burden per population rate in many low and middle income countries is on an age adjusted basis the greater than the burden in advanced countries. We just overall live longer and live better. Keep in mind the fundamental epidemiological fact is everyone dies once. So ultimately you're going to count everybody and attribute to some disease. So the real question has to also be an age specific question. It's not simply counting a death at age 102 is not the same as at 60 or 52. So these all have to play into it but when you look at those with any objectivity the stark burden of these non-communicable diseases comes through in the low and middle income countries. To the back please. Thank you. Very much Elliott Pence from the Whitaker group. The term NCDs encompasses such a variety of different diseases and health challenges. The effects seems to be so great and the populations on which the challenges will inevitably take place are in some of the most you know least resourced settings. If you were say the permanent secretary for Ministry of Health in Tanzania what are the for lack of a better term the surgical strikes what are the priorities you mentioned tobacco are there any other sort of specifics that you could offer. Well thank you for the question. The first thing that I would say to every minister of health and finances you should look at the burden of disease in your own country. And don't be I would say blinded by these general labels as you point out they cover wide varieties and actually keep in mind it's always a little bit unsatisfactory to define something by what it's not. You know so this is not non-communicable disease well that's a big basket right. It does have the virtue that it's an exhaustive alternative that it's either communicable or non-communicable that covers everything. It's sort of like being awake or asleep you know pretty much that's what you do during the day. Although I can't tell with some of you exactly I'm not 100 percent sure. But now coming back to the to the point so I begin with the burden of disease in your country. And then again the great the great insight and virtue of prevention is how broadly effective critical interventions can be across a spectrum of these problems. But among the top the top targets certainly are going to be tobacco diet and exercise. You will find opportunities especially in maternal and child health in many many countries especially where you're dealing with still high infant mortality. You will find opportunities for reduction of environmental pollutants and other sources especially in countries that have high indoor air pollution. And you will find other targeted preventives including screening and particularly use of vaccines so that's for the communicable disease. The things that you can do that will have great and widespread benefit but once you get past you know five or ten of them you've probably hit 80 to 90 percent of your problem. And so it's not like you need to figure on four dozen lines of work you could end up picking three or five and really dent the problem. Yes let's go back over here to the one in the red jacket please. Thanks Catherine and thank you Dr. Fine but I'm no more in the clundu from the Embassy of South Africa. I just was just wondering you as you were framing the nature dynamics and the extent of this problem globally. You identified it as a problem that has come on across the board. I was just thinking if what your views were in terms of taking a leaf from what the HIV community has done in terms of globally mobilizing for resources for epidemiological surveillance for institutions to be in place. Do you think that this community the NCD community perhaps could benefit from that. Thank you. Thank you very much for your comment and question. The lessons from the experience with HIV I think are very very relevant to every effort for disease control in the world. The facts of HIV although it's a communicable disease it's also a chronic disease and it's increasingly a disease that is being managed in many countries in a way that people are living much more full and rewarding lives. Now the relevant part of the HIV experience as you described isn't so much the clinical but rather the social mobilization that HIV demonstrated was possible in fact that it fostered. And I think one of the features that made it possible as a global movement was this shared nature where HIV was and is a problem both in industrialized and in developing countries. It was especially in the early days of the outbreak a disease problem that was appreciated as a huge threat everywhere. And that was an important feature in the mobilization. In some ways maybe the difficulty we have with heart disease or cancer is that they are too familiar. We're too accustomed to them. They've been around for a long time. It's not something we point to and say it's just a rising it's an emerging problem. It is in fact a dominating problem but it's not brand new. And so one of the challenges for social mobilization will be in under the circumstances where you are trying to mobilize concerted action around a problem that has many of the qualities that make it, if you will, right for action. It's widespread prevalence. It's dominating impact on a population. It's susceptibility to intervention. It has those qualities but it still has to have what's the precipitating event. What is it that will mobilize people? And that's why I think one of the reasons that this kind of gathering at the UN can be potentially very important because it's at least a moment where we can galvanize our attention to the problem. And we need that in order to make the kind of movements possible that you're describing. Yes, we have another question here at the center table please. The microphones are coming from a bit of a distance. Thank you Dr. Feinberg. As we prepare for the first UN submit on NCD, I think it could be useful to be reflective. And as I said the question, what went wrong? What is that the global health community collectively has not been able to bring NCD to the forefront of the public health agenda, the way we've been able to do with maternal and child health, malaria, TB, HIV, so on and so forth. And on those, to be fair there have been a few, I would say success or bright, a good development for example the framework convention for tobacco control which was really an achievement. But by and large the global health community has been able to bring the NCD to the forefront in a comprehensive systematic manner the way we are doing now. So what went wrong? Thank you. The short answer is I don't know. But I'm very glad to see it's maybe starting to go right. I think that we have a lot of problems in health that we tend to overlook and just take them for granted. We tend to think that they are part of the landscape. They're just in the backdrop. They're just the way things are. We don't recognize them for what they are as preventable, avoidable sources of premature death and disability. I would submit that in the United States that's kind of the way we think about violence. Most of us just kind of take it for granted. Well, yeah, people get shot every once in a while. Violence occurs. This is just the way it is. But it isn't that way in most countries of the world. It's distinctly that way in the United States of America. But we haven't quite fully awakened to it. I think in the same way for reasons we were discussing before, maybe because they're so familiar. They've been around for so long. There's not in a day when you say, aha, it's now upon us that the noncommunicable diseases have an easier time just looking like they're part of the background, part of what we live with, part of what we expect. And I think a very important role for health leadership is to call out those preventable sources of premature death and disability and identify something to do about them. So I can't really explain why it has been relatively neglected in the past fully, but I can tell you that I'm very, very glad that's changing. We have another question over here to the left if we could have a microphone up here in the front on the left, please. Edward Kadunk, Pan American Health and Education Foundation. I wanted to ask a question about the private sector involvement in this problem. It seems to me that the traditional public health solutions to public health issues has a hard time being applied to this phenomenon that we're seeing. And at the same time, a lot of the solutions reside in the private sector. So my question is, how can we develop a strategy that helps the international organizations work more closely with the private sector in a solution of these problems? International public health organizations typically have a large amount of reticence in working with the private sector. They either see them as providing products that could pose the appearance of a conflict of interest or that they produce bad products, bad products being ones that have lots of sugar, lots of salt, lots of fat. How do we get that kind of a dialogue and cooperation going? Because I think the issue larger than funding is how much of this can be done from the private sector side without the need for public investment. Well, thank you for the comment and the question. One of the things I was very pleased to hear from Catherine's comments earlier is that the very next session in this series at CSIS is going to tackle exactly this issue, so I'm sure that there will be an opportunity to delve more deeply into the opportunity. But I do think you put your finger on the really critical nature of this challenge, and that is that the solutions do not reside in the traditional or predominantly in the traditional public health strategies and interventions alone. They require a mobilization of intense engagement across the public and private sectors. They involve the engagement across the education, agriculture, commerce, and environmental sectors beyond what we typically think of as just a health project intervention. And I think that the organizations that offer the forum for the kind of dialogue that you're describing where you can bring together the private sector, the public sector, the NGO sector, and public interest groups, as well as representatives of the public. You can have an honest exchange, and you can design and devise fresh ways of thinking, and maybe even some pilots, and demonstrate how successes can be mounted. All of these, I think, will have a place. The challenge of the noncommunicable, the chronic diseases, the heart disease, the cancers, the diabetes, and all the others that we are focusing on, they will not yield to a single thrust of an intervention, and the problem is solved. They are going to require a variety of sustained interventions, and a big part of that, I believe, is going to be just what you call for, which is the collaboration and intersection of the public and private sectors. So I'm hoping that this will have some opportunity for further elaboration in the next discussion here. Yes, we have a question here in the back. The second table from my left is the right. Thank you. Duele Tulen University. I was wondering if you look at the health workforce in both countries that will be needed to really tackle the NCDs in addition to communicable diseases. Because when the HIV-Aid program started, they said most of us can't handle because we don't have the workforce. Have you looked at the one for the NCD? Yeah. It's a very important point that you raise on the health workforce and its preparedness to cope with the burden of the noncommunicable diseases. There was just recently published in the Landsat a report of an independent global commission on the future global health workforce that describes the needs for the workforce at all levels to have the kinds of capacities and mutually reinforcing training and practice patterns that will more efficiently deliver the services that people need. When you look honestly at the situation in many countries, the facts of the matter are that there is a dearth of adequately trained available health professionals to care for and meet the needs of that population. That is a fundamental reality and a challenge to all of us. Other countries, including the United States, are places that people come who are health professionals and are able both logically and individually to pursue a career that makes sense for them here, but which in turn means that they are not available to contribute to solutions to health problems in their home countries. And so that's another part of the mix, including the idea of getting opportunities for more health professionals from countries like the United States to spend time in countries where the needs are even much greater. So that's another part of a potential solution here. But overall I would say that the infrastructure, the health workforce, the availability of necessary drugs, devices, other intervention tools, these are all part of a package of what you need to be thinking through as you design intervention strategies that you have a prospect of working. So your point is I think very well taken. There are a number of questions out here and we're getting close to the time of our close. So let me take two or three questions at a time and then we'll ask Dr. Feinberg to answer them and wrap up. Let's see, there's one right over here, please. Thank you. Fatou Matabachili from HHS. My question is it makes sense for the global community to tackle infectious diseases. But what should be the WHO message for developed countries to tackle this at the global level? We have our own problems here in the U.S. Why should we have other countries deal with NCDs? Why should we do it? Thank you. So then there was another question at the table in the back, please. One I'm going to maybe answer somewhat of a previous question about the workforce. I don't know if many people here know, but NIH along with PEPFAR and many other federal agencies have put together a medical education partnership initiative for workforce training in the medical and research fields in many of the developing nations. That's $130 million initiative. So I think that is the start, $130 million over five years. That's the start of an initiative to really train the workforce. And a lot of that initiative is to really keep the workforce in the developing nations because a lot of the times this trained cadre of medical researchers and doctors will leave the developing countries. Another question that I have actually is what can we do as a nation in order to dovetail with the efforts of other nations, both developed nations as well as developing countries in terms of really joining forces and reducing the burden of non-communicable diseases, both from the research level all the way up to the government policy level. Thank you. Thank you. And let's take one more right here in the center please. My name is Yuan Liu from one of the National Institutes of Health Institute, the National Institute of Neurological Disorder and Stroke. I'm very glad that you mentioned about neurodegenerative diseases could be a big burden for global wise. So my question actually is more a suggestion for CSIS for future seminars. So in your very inspiring speech you talk about actually it's two of the central interests of the U.S. to support global health research. What we learned from other countries can largely benefit to our country. But in our country both at the public level and even at the scientific research community level because funding now is very tight people have felt very hesitant to send money abroad to study global health issues. So that's the imbalance you mentioned about underfunded and not meet the task with the need. So my suggestion is to collect a series of success stories that happen in global health research that really largely benefit our country. For example in heart or stroke like our institute is responsible that can be translated to the prevention and treatment in this country. And then put that as a material for education or information for our congress for the public and for the scientific research community then we can have more funding for global health. So a question about the U.S. is struggling to address its own problems here. Why does that make sense for us to help others? Another about how do we dovetail and coordinate with other countries to ensure that we make the maximum impact for this challenge and then a suggestion but also just a reflection about the importance of collecting success stories. Thank you very much for the questions and the comments. I appreciated also the comment about the training program that's initiated under the NIH and PEPFAR now. It's a very important component of the U.S. initiative and an important element to keep in mind. I think too that the making the case several of the points were really around how do you make the case for U.S. engagement in noncommunicable diseases. And why does it seem more logical for communicable diseases as compared to noncommunicable? I think we have to ask ourselves the question why do we care especially about the communicable disease? Well maybe you'd say well those diseases we care about because they really do represent a big burden in the other countries and they could even affect us. If we don't stop certain diseases it could come to our shores. Well I think you make exactly the parallel arguments with some slight variations when it comes to noncommunicable disease. The reason to deal with noncommunicable disease begins with a recognition that we want to reduce the burden of illness in the world. If you begin with that assumption then you want to know well what is it exactly that's producing that burden? To what extent is it one disease or another and to what extent can interventions that we might mount benefit across a spectrum of those diseases? And when you begin to lay out the case that way many of the chronic noncommunicable diseases really come to the fore as targets of opportunity and humanitarian need both. That we can by investing smartly really make a big difference for the world. I really appreciated the suggestion that we need to bring forward the case examples that will show where interventions and lessons from other parts of the world have redounded to the benefit of the U.S. public because that will help reinforce the notion that research is a global enterprise and the knowledge that is gained anywhere can be of use everywhere. And that I think is a very important message to reinforce by example as was suggested and I think that's a wonderful challenge to those who want to make the case to be able to come forward with these examples. There's no doubt and let me say the pharmaceutical companies have discovered long ago that they can certainly conduct many trials less costly and with high reliability in different parts of the world. They don't have to conduct all those trials in countries like the U.S. or Western Europe. And I think there's some real lessons to be learned again from the private sector in this as well that may apply to the public. And finally I would say that to my mind a way of ensuring the dovetailing of resources in a way that's genuinely contributory to the needs of the developing countries is to allow the leadership in the developing countries to have a very powerful voice in what is done. It's the partnership concept that is respectful of the prerogatives of the recipient who is in the best position to know about priorities, coordination and needs. And that I think is a good point for us perhaps to conclude. So thank you all very much. Dr. Feinberg, thank you for taking the time this afternoon to share your experience insights and perspective with us. I hope you all will agree with me that this was a fabulous way to start the speaker series and provide a broad overview and set of challenges for us to think about and consider as we look toward the U.N. summit in September. Let me just remind those of you who weren't able to pick up a copy when you came in. The Institute of Medicine has recently released I think it's a summary of a report on the effects of cardiovascular disease in low and middle income countries. And so there are copies outside if you would like to pick one up on your way out. And finally, let me just remind you again that our next event in this series will feature Jean-Luc Batel, Medtronic, on tackling the global NCD epidemic, how the private sector can and should be part of the solution. This will take place on February 16th at a slightly different location. We'll be at the Kaiser Family Foundation offices over in Metro Center and that will be from 9.30 to 11 a.m. We'll look for information about that and look forward to seeing you there. Thank you all.