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Outcomes Of The Cambridge Conference On NCDs

Outcomes Of The Cambridge Conference On NCDs


Story by The Food Revolution Team

Last Month, the Humanitarian Centre – a Cambridge, UK based international relief and development network – in partnership with the Cambridge Institute of Public Health and the Centre for Science and Policy ran a Post UN Summit Conference on Non Communicable Diseases (NCDs).

During the conference, which was a follow up on the UN Summit last September where world leaders unanimously adopted the Political Declaration on NCDs, presentations took place from world-renowned experts in NCD research, policy and practice. Outcomes of this conference will be translated into key messages and policy recommendations on the potential to alleviate the harm of these diseases, particularly in developing countries.

The reception was attended by a large audience and a panel of speakers including Malcolm Bruce MP, International Development Committee Chairman, Rushanara Ali MP, Shadow Minister for International Development and Professor Nick Wareham, Director of the Medical Research Council Epidemiology Unit and Centre for Diet and Activity Research (CEDAR), University of Cambridge.

First recommendations to be announced from this conference include that government should:

“¢ Advocate for the inclusion of NCDs in the post-Millennium Development Goals (MDG) framework.
“¢ Offer expertise and technical assistance to support national governments in developing countries to develop national plans on NCDs.
“¢ Fund and support research to identify effective NCD interventions.

While this conference looked mainly to the UK government for advice, strategy and action that can be taken on NCDs in developing communities, we look forward to more countries and governments addressing this important issue.

Why Are NCDs Important?

60% of deaths in the world are due to NCDs “” 80% of which occur in developing countries””yet they attract only 3% of donor aid (1). Unhealthy diets (especially those which have a high content in fats, free sugars and salt) and physical inactivity are among some of the leading causes of non-communicable diseases (NCDs) including cardiovascular diseases (CVD), type 2 diabetes and certain cancers.

Obesity is already a global problem in both developed and developing countries and its health costs will impact all countries facing it with 2.8 million people dying every year as a result of being overweight or obese(2). The economic impact will be much more damaging for those countries with lower incomes that are less able to afford the rising costs.

It is therefore vital that these recommendations are taken on board, that the conversation continues in countries across the world and that NCDs stay on governments agendas to ensure that more meaningful steps are made and an agenda is put in place to reduce and prevent NCDs, before we have an even bigger problem on our hands to pass on to the next generation.

The Food Revolution Team

Sources:
(1) Humanitarian Centre
(2) Global status report on noncommunicable diseases 2010


Why health system resilience is key to a sustainable future

Resilience in the context of global health may not be a phrase that trips easily off the tongue, yet the COVID-19 pandemic has thrust this critical issue to the forefront of our collective minds in the pursuit toward access to healthcare for all. The world is waking up to the need for a transformative shift to ensure a sustainable and resilient future.

Functioning and sustainable communities are dependent on the health of their populations, yet non-communicable diseases (NCDs) such as diabetes, heart disease and respiratory conditions are the world’s biggest killers and are responsible for 71% of deaths globally. Some 41 million people still die every year from preventable NCDs. 1

Historically considered conditions of high-income countries, four out of five people with an NCD now live in low- or middle-income countries (LMICs), 2 where patient outcomes are also impacted by variations in healthcare provision. In such developing countries, disadvantaged populations are also disproportionately affected by the COVID-19 pandemic 3 – exacerbated by the synergy with NCDs 4 – and further strengthening the argument for greater health equity as part of the ambition toward sustainable and resilient health systems.

What this pandemic has made clear is that taking ambitious, proactive measures to future-proof global health systems and translating these measures into action on the ground is paramount if we are to address this crisis to be part of a future where we can help people live healthier lives and make equitable access to healthcare for all a reality. This is the vision for AstraZeneca where sustainable healthcare for all is front and centre of our company agenda. 5


Background

Over 60 % of global deaths are attributable to non-communicable diseases (NCDs) [1]. With most developing countries experiencing a shift in disease burden away from communicable disease to NCDs, this contribution is expected to grow. To respond effectively, it will be crucial to understand these epidemics better: both how the burden of disease is anticipated to change over time based on current trends (e.g. demographic change, changes in risk factor prevalence, or changes in diseases incidence), and the effects that different interventions might have. This is important for planning health services and for developing an evidence base to inform public health policies aimed at reducing the burden of disease. While modelling is often not well understood and is frequently criticised, we argue that modelling NCDs has an important role to play in informing how society responds their increasing burden on population health.


Outcomes Of The Cambridge Conference On NCDs - Recipes

African countries are not on track to achieve global targets for non-communicable disease (NCD) prevention, driven by an insufficient focus on ecological drivers of NCD risk factors, including poor urban development and the unbridled proliferation of the commercial determinants of health.

As the risk factors for NCDs are largely shaped outside the healthcare sector, an emphasis on downstream healthcare service provision to the exclusion of upstream population-level prevention limits the goals of universal health coverage (UHC) and its potential for optimal improvements in (achieving) health and well-being outcomes in Africa.

The political will for UHC in Africa will miss the opportunity to turn the tide of this emerging NCD epidemic in Africa, if not oriented to a systems for health rather than a solely healthcare-centric approach. A successful approach needs to proactively incorporate wider health determinants (sectors)—housing, planning, waste management, education, governance and finance, among others—in strategies to improve health. This includes aligning governance and accountability mechanisms and strategic objectives of all ‘health determinant’ sectors for health creation and long-term cost savings.

Researchers have a vital role to play, collaborating with policy makers to provide evidence to support implementation and to facilitate knowledge sharing between African countries and globally.

The third sustainable development goal (SDG), ensuring healthy lives and well-being for all at all ages, although comprising multiple components, is often strongly linked with the concept of universal health coverage (UHC) and its underlying principles of equity, quality and financial protection. The importance of addressing the upstream determinants of health as a vital accelerator of progress in achieving the SDGs has been recognised1 however, in practice, the implementation of UHC has often been restricted to a disease-fighting, healthcare-centric approach. This constrains the ability to achieve WHO’s definition of health as the attainment of ‘complete physical, mental and social well-being’. Vast amounts of experience and research show that health outcomes are shaped by multitiered and multifaceted factors that do not stem solely from the healthcare sector.

The WHO recognises the importance of health determinants, noting that UHC comprises much more than just healthcare and that taking steps towards UHC means steps towards equity, health-promoting development priorities, social inclusion and cohesion, and including public health campaigns.2 Building on this, we argue that improved upstream planning and policy may even reduce the need for public health campaigns. Implementation of this more comprehensive and holistic approach to UHC is essential to ensure the full realisation of demographic dividends, particularly in an era of non-communicable diseases (NCDs), many of which can be prevented through upstream interventions that are not typically considered as healthcare.

Africa is experiencing a double burden of disease,3 with the burden of NCDs like type 2 diabetes increasingly borne by disadvantaged populations. In addition to mortality and morbidity, NCDs strike people during their economically productive years,4 5 with significant implications on wealth of individuals, their families and their countries. Sub-Saharan Africa has the largest cohort of young people in history,6 coupled with challenges related to rapid urbanisation, climate change and insecurity. Efforts to optimise the benefits of health and wealth need to be prioritised.

NCDs are fundamentally related to behavioural risk factors, which are affected by complex ecological drivers intersecting in local social, cultural, policy and economic contexts. They are further impacted on by global dynamics, such as the globalisation of unhealthy diets and lifestyles, short-term donor-driven governance priorities and the unbridled proliferation of industries that produce harmful substances, such as tobacco, alcohol and ultraprocessed high sugar, and high-salt foods. Additionally, existing public awareness programmes are often not effective, and advocacy for NCDs is weak compared with the support given to other epidemics such as HIV/AIDS.

Fragile health systems conspire with these other factors to ensure that African countries are way-off track to achieve global targets for NCD prevention and management.4 In 2001, African nations adopted the Abuja Declaration, pledging to allocate at least 15% of their national annual budgets to health spending. Yet, only three countries in the African region have attained the goals of the Abuja Declaration and the High-Level Taskforce on Innovative Financing for Health.7 Where healthcare spending is low, healthcare spending on NCD is even lower in a region where donors drive health financing, most donor finance is still oriented towards communicable diseases, with about 1%–2% dedicated to NCDs.7 Out of pocket expenditure results, where NCD care is needed, with poorer households spending more of their per capita household income on NCDs.8

The result? An exemplar is diabetes. Even if countries meet the SDG goal of decreasing mortality from diabetes by one-third, or if they reduce age-specific and sex-specific prevalence to their 2010 levels (a key aim of the WHO NCD Global Action Plan), the economic burden of diabetes in 2030 will still be 61% higher than that in 2015.9 In South Africa, the estimated costs for implementation of local guidelines to achieve reasonable access to care for cardiovascular diseases would substantially impact on the ability of the health system to care for other illnesses.10 For most African countries, to achieve true UHC to manage NCDs by 2030 would require an unprecedented investment in healthcare services.

So, what can be done? (See box 1.) The crippling cost implications of waiting to address NCDs downstream in the healthcare system are clear. In the context of limited resources, addressing upstream determinants will translate to long-term savings by ultimately reducing the burden of diseases that needs to be addressed within the healthcare system. Countering the notion that this is impossible, given that African countries are struggling to achieve narrow definitions of UHC, we argue that these countries cannot afford not to explore innovative approaches to reduce the need for healthcare to reduce healthcare costs in the long term. It is imperative to evolve the implementation focus of UHC from one of solely reactive provision of health services to one that incorporates primary prevention to flatten the current trajectory of the NCD epidemic in Africa. Sectoral silos need to be broken down to achieve this. For example, obesity, an important risk factor for diabetes, is related to access to infrastructure that encourages an active lifestyle: transit systems, built environment features that promote walking, cycling and green spaces.11 This infrastructure needs to be safe, clean, functional and of reasonable quality. This is the remit of urban planning, waste management and local governments. Smoking, which acts synergistically with diabetes to cause disability and death, is driven by access to cigarettes, harmful advertising and messaging from the tobacco industry that encourage adoption of smoking by young people and stressful living conditions that predispose people to take up unhealthy habits, among others. These factors are within the areas of responsibility of housing, trade policies and government sectors responsible for advertising. Ensuring access to environments that promote healthy eating to prevent obesity is predominantly a matter for policies largely developed outside the healthcare sector. Therefore, beyond healthcare delivery, healthcare practitioners should be encouraged to advocate for such policies that protect health through addressing upstream determinants.12

Recommendations for action to breakdown non-communicable disease (NCD) silos

Policy makers

Systems for health must work alongside healthcare services: Reducing the burden of NCDs is a complex problem requiring healthcare services to intersect with multiple other systems that affect health.

Health financing should be focused on producing health rather than managing disease: Multisectoral action to reduce the NCD burden requires long-term (extending beyond one policy cycle) budgeting structures and accountability mechanisms for co-benefits across the multiple systems that drive health.

Health creation must be central to development: Africa has the opportunity to redefine urban development to ensure inclusion of health promotion solutions. Measures of success should be grounded in the health of the populations.

Policies should align to create health as an outcome: Policies directly or indirectly resulting in disease have no place alongside those that promote access to care for those diseases.

Policies and spending should reflect country needs: Spending and policies should not reflect richer donor country interests but should be reoriented to address health outcomes more systematically and sustainably, including through upstream, multisectoral action.

Research community

Research and policy collaborations should be the norm: Academics and policy makers should come together to discuss policy priorities for reducing NCDs and how to provide evidence to support those priorities.

Investment in platforms for knowledge sharing: South–South and North–South learning should be facilitated to ensure rapid learning between cities and countries in Africa.

Support frugal innovation for health (beyond healthcare): Long-term frugal innovation is needed to make growing cities and societies spaces that promote health and equitable thriving. African philanthropists can play a role in this innovation.

External research funders and donors

Research funders and development assistance for health donors: should prioritise funding in line with disease burden and recipient country defined need, which encourages long-term approaches to health creation.

Achievement of UHC that does not bankrupt health budgets or restrict disease coverage so much as to be worthless rhetoric requires innovative policy making, intersectoral accountability mechanisms and financing structures, which encourage multisectoral action. Figure 1 highlights the importance of intersectoral action by proposing a diverse range of services that can be considered ‘health services’ by virtue of the impact they have on population health. This shows the familiar healthcare service that ultimately aims to reduce morbidity and mortality from all diseases this is usually assessed at an intermediate level using indicators such as disease control, admissions and other healthcare episodes. The figure also highlights how transport and planning, for example, could be considered health services by virtue of the services these systems provide for health. For example, transport and planning policies that prioritise obesity and cardiovascular risk reduction by equitably creating physical activity opportunities and reducing air pollution exposure can measurably contribute to reducing diabetes and cardiovascular disease burden in the long term thus providing a health service. While this action does not necessarily need to be implemented under the ‘UHC’ umbrella, the political momentum behind UHC provides an opportunity to raise the profile of such approaches to achieving health for all. To be clear, we argue that for long-term healthcare savings and population health, there is a need for a focus on upstream prevention for health creation and protection, not limited to early detection in those already at risk of NCDs, alongside current strategies to treat existing disease. Other examples of such upstream approaches include tax on sugar-sweetened beverages and aligning performance goals of urban development policies with improving healthy food consumption and increasing active living.

Examples of multisectoral action for disease prevention.

There are promising developments and policy opportunities that can be leveraged to ensure that development produces health as an outcome in Africa. There has been a history of Healthy Cities Initiatives in Africa13 with some cities such as Dar es Salaam and Cape Town developing healthy city programmes without the support of international organisations. In addition, there is an Inter-ministerial Taskforce on Health and the Environment in Africa, which convenes health sector and environment sector experts and ministers across Africa to address the environmental threats to human health.14

The first and second WHO Africa Health Forums in 2017 and 2019 have recognised NCDs as an emerging threat in Africa and the need for intersectoral action to address the social determinants of these diseases.15 The Commonwealth Ministers of Health meeting and World Health Assembly in May 2019 also provide an opportunity to build on these initial calls to action to critically engage with constraints and enablers of implementing intersectoral approaches to NCD prevention and to foster transdisciplinary partnerships with researchers to develop and evaluate knowledge-based, contextually relevant, innovative and bold interventions to create health that leaves no one behind.


Alcohol and non-communicable diseases (NCDs): time for a serious international public health effort

AER Centre for Alcohol Policy Research, Turning Point Alcohol & Drug Centre, Fitzroy, Vic., Australia School of Population Health, University of Melbourne, Australia and Centre for Social Research on Alcohol and Drugs, Stockholm University, Sweden, Centre for Addiction and Mental Health, Toronto, Canada Dalla Lana School of Public Health

Department of Psychiatry, University of Toronto, Canada and Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Germany

Alcohol and Drug Abuse Research Unit, Medical Research Council, South Africa Department of Psychiatry, Stellenbosch University, South Africa and Global Alcohol Policy Alliance, London, UK. E-mail: [email protected]

AER Centre for Alcohol Policy Research, Turning Point Alcohol & Drug Centre, Fitzroy, Vic., Australia School of Population Health, University of Melbourne, Australia and Centre for Social Research on Alcohol and Drugs, Stockholm University, Sweden, Centre for Addiction and Mental Health, Toronto, Canada Dalla Lana School of Public Health

Department of Psychiatry, University of Toronto, Canada and Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Germany

Alcohol and Drug Abuse Research Unit, Medical Research Council, South Africa Department of Psychiatry, Stellenbosch University, South Africa and Global Alcohol Policy Alliance, London, UK. E-mail: [email protected]

Together with smoking, diet and physical inactivity, consumption of alcohol is among the four most important risk factors for non-communicable disease (NCD). Alcohol consumption, especially heavy consumption, impacts on cancer, liver cirrhosis and stroke. To reduce the burden of NCD, effective alcohol policies should be implemented locally, nationally and internationally.

Each year, in connection with the opening of the General Assembly sessions, the United Nations holds a special session on an agreed-upon topic. In 2011, the topic is non-communicable diseases (NCDs), arguing for their inclusion in the Millennium Development Goals, with the primary goal of emphasizing the importance of addressing such diseases in order to reduce the global burden of illness, not only in rich countries, but also in poor countries as a consequence of major epidemiological transitions 1, 2 .

While NCDs as a category covers a broad range of illnesses, primary emphasis has been put on cancer, heart disease, chronic respiratory diseases and diabetes 3 . Despite the fact that each disease has its own specific aetiology, there are risk factors which reach across many of the major NCDs including, in particular, several behavioural risk factors: unhealthy diet, lack of exercise, tobacco smoking and alcohol use.

One approach to limiting the play of such behavioural risk factors is based on a perspective of individual choice and responsibility. The premise is that educated consumers will act in their own long-term interests, even in the face of heavy marketing and promotion controlling behaviour in such an environment may even be regarded as a test of virtue 4 . A perspective that educating the consumer is all that is needed has been the approach in recent times globally, not only in market economies. Many low- and middle-income countries have also adopted this approach, especially the emerging economies in Asia, with high economic growth rates. The experience of the second half of the 20th century was that such laissez-faire approaches are not a successful strategy for limiting NCDs.

A second approach has been to proscribe particular forms of consumption altogether. While this has obvious difficulties in the case of diet, for tobacco and alcohol there have been prohibitions on use in various forms and times. Again, the experience has been cautionary such prohibitions tend to succeed only when backed up strongly by religion and culture.

A third approach is through regulating the market to channel and influence consumer behaviour towards restrained and less harmful use 5 . Addressing such ‘upstream’ factors can be quite effective, as has been shown for alcohol and tobacco 6, 7 , but this strategy of balancing conflicting interests is inherently unstable. Because it involves tolerating a certain level of NCDs and other harm from the behaviour, it involves compromises and is easily seen as unprincipled. Regulating the actions of private interests in the market became more difficult in the late 20th century, in an era of globalization, free trade agreements and free market ideology 6, 8 . Given the political influence of market interests, substantial and sustained counter-pressure from public health interests is required to prevent regulatory capture.

A regulatory approach thus requires substantial and sustained efforts in the public health interest. It will not be enough for the United Nations to pass a resolution at the Special Session and leave it at that. This is an issue for all the behavioural risk factors for NCDs, but it is especially an issue for alcohol. Alcohol is now included regularly in NCD discussions, such as the preparatory meeting for the September session in Moscow in April 2011 9 , but it regularly receives the least attention of the major risk factors. There are several reasons for this. For instance, the health-protective effects of alcohol in ischaemic disease for the middle-aged and older people 10 have confused and inhibited efforts to curtail harmful use of alcohol, even though the net effect of alcohol on cardiovascular disease—setting all else aside—is negative. Furthermore, moving on alcohol is more difficult because it is so much more part of the daily life of decision-makers: the affluent and powerful regularly use alcohol, whereas smoking tobacco or being overweight are increasingly characteristics of the poor and socially excluded. Finally, alcohol industry interests operate effectively in political spheres to minimize the efforts of public health proponents to address the impact of alcohol use on NCDs, among other harms. This occurs both at international levels, with increased global concentration in the spirits and beer industries 11 , and nationally and locally, with widespread nets of producers and distributors—whether cider makers and whisky distillers in the United Kingdom, vintners in Australia and southern Europe, fruit wine producers in Finland or brewers in Belgium, India and China.

Against these forces the public health effort on alcohol is weak, particularly at the international level. To counter the pressures from globalized industries and from free-trade treaties and settlements, there is no Framework Convention on Alcohol Control 12 with a secretariat to increase its effectiveness, as there is for tobacco. As a first step forward, there is a new World Health Organization (WHO) Global Strategy on Alcohol 13 which sets out an initial framework for action on an international basis, but the resources available for implementing the strategy are puny. Whether as a reflection of behind-the-scenes pressure from the alcohol industry to starve the effort, of the ambivalence of political classes about alcohol, or of a withering of national commitments to international aid, the WHO alcohol programme is forced to operate on a shoestring budget, with minimal staff and programme resources.

Meanwhile, recognition of the necessity of addressing harmful use of alcohol in order to attain public health objectives increases. Alcohol plays an important causal role in the aetiology of NCDs. While this is particularly the case in countries in the former Soviet Union 3 , the problems extend across the globe. Alcohol is the third leading risk factor in the global burden of disease for death and disability in general 14 , and this is calculated primarily in terms of the adverse effects of drinking on the drinker. There are also large adverse effects of drinking on others 15 , not counted in the health statistics. The case for increased priority being given to act on alcohol to address NCDs and other public health concerns is now very strong. In this context, the relative lack of action on alcohol is increasingly indefensible. The September meeting at the United Nations is an occasion for remedying this, and for taking concrete steps to increase the resources at the international level devoted to alcohol policy issues.


Study Data And Methods

In what follows, we review some of the major findings from the literature examining food insecurity and health that takes into account both self-reports of health and clinical outcomes. We break the major findings down into three broad age categories: children, nonsenior adults, and seniors. Within each of these categories, we highlight work that illustrates salient points regarding the relationship between food insecurity and health.

Our review is confined to research on food insecurity and health in the United States and, to a limited extent, in Canada, since these two countries measure food insecurity in a similar fashion. A parallel literature has examined this topic in non-high-income countries, but that is beyond the scope of this article.

Along with this geographical concentration, our review concentrates on research that with few exceptions has appeared in peer-reviewed journals since 2001. While most of the papers use the USDA’s measure of food insecurity (defined above) as the key variable of interest, in some cases we include papers that used variants on this measure of food insecurity. To reflect the interdisciplinary nature of food insecurity research, we include papers in journals in disciplines that reflect the most recent work in this area, especially in the fields of economics, agricultural economics, internal medicine, pediatrics, nutrition, public health, and social work. Because different disciplines focus on different aspects of food insecurity and health, our key search terms included food insecurity and health and food insufficiency and health . We also conducted more refined searches in which we replaced the word health with well-being , depression , child (or senior ) health , and so on.

Because of space limitations, we were unable to include all papers that examined the relationship between food insecurity and health outcomes. Thus, ours was not a meta-analysis. Instead, we cite at least one paper for each health outcome that has been found to be associated with food insecurity. When multiple papers found similar results, we restricted our coverage to more recent papers that used state-of-the-art methods and the standard food insecurity measure. As a result, most of the work we cite has been published in the past seven years.


V. CONCLUSIONS

This paper has provided a state-of-the-art review of the link between specific macronutrients and foods and CVD and summarized how the global food system contributes to dietary patterns that greatly increase the risks for the population to experience ill health. While many perceive food consumption as an individual choice driven by the desires of consumers for tasty food, linked with rising incomes and urbanization, we have shown that the food system and all the stakeholders within it should play a major role (307).

Short term controlled-feeding studies with CVD risk factors as outcomes, long term prospective cohort studies with CHD, stroke and T2DM as outcomes, and a limited number of RCTs with CVD as the outcome collectively show that multiple aspects of diet substantially influence CVD risk. However, similar data are needed from LMIC as dietary patterns differ in various regions of the world and the context in which foods are accessed differs markedly.

Based on the current evidence, the optimal dietary pattern to reduce CVD is one that emphasizes whole grains, fruits and vegetables, legumes, nuts, fish, poultry, and moderate dairy and heart-healthy vegetable oil intake this pattern will likely reduce the CVD risk by about a third. This healthy dietary pattern needs also to be low in refined grains, added sugars, trans-fats, SSBs, and red and processed meats. The traditional Mediterranean-type diet provides a well-tested prototype for this healthy dietary pattern. Given that we now understand the components of this diet sufficiently, it may be possible to translate this pattern to other regions, with appropriate similar food replacements based on food availability and preferences (see attached Table S1). Despite significant advances in our understanding of optimal dietary patterns to prevent CVD, additional research including large cohort studies and RCTs of dietary patterns are needed in different regions of the world to address existing knowledge gaps. This includes evaluation of the impact of specific fruits and vegetables, types of dairy foods, types and amount of carbohydrate, optimal cooking oils, regional specific dietary patterns, and cooking methods. Finally, we acknowledge that while this paper is focused on CVD, dietary choices and recommendations should also be made with consideration of the environmental implications of food choice (i.e., the environmental impact of poultry, livestock/cattle production, and diminishing wild fish stocks), and the role of diet in other disease processes. Human health must be linked to environmental health—the basis of the new Sustainable Development Goals (241). Additionally, modifications to our recommendations may provide improved protection against cancer or neurodegenerative or auto-immune diseases.

Policy actions and interventions that improve food supplies and dietary patterns have social, cultural and environmental benefits. There are many opportunities to increase access to healthy food that are also likely to have significant environmental benefits. Health providers throughout the world can lead by advocating for action in the food system, as well as in food environments and behavior change communication. So too can other professionals, civil society and public interest organizations, influential writers and journalists, and organizations of chefs and gastronomes. A synergistic systems approach is essential. The challenge to create and sustain what is healthy and change what is unhealthy is compelling because improving the nourishment that goes into our bodies can have wide-ranging benefits in improving the health of societies and environments. A second major challenge is to identify and implement effective food systems and solutions and evaluate the national and local level policy actions underway to improve our diets.

Table 1

Summary of evidence of associations between major foods and cardiovascular disease.


Bottom line: The Paris Agreement is an international agreement for mitigating and adapting to climate change. It relies on non-binding, country-specific goals.

What's the history of the Paris climate agreement?

Let's begin this history lesson with the first major international conference on environmental issues: the United Nations Conference on the Human Environment in June 1972. At this conference, world leaders and non-governmental organizations from 113 countries gathered in Stockholm to create 26 principles for environmental betterment and form the United Nations Environmental Program (UNEP). Today, the UNEP continues to spearhead and manage many global environmental projects and policies.

Since that time, the UN has facilitated several more international environmental conferences around the world. One of the most noteworthy conferences is 1994's Earth Summit, held in Rio de Janeiro. At the Rio Conference, world leaders created the United Nations Framework Convention on Climate Change (UNFCCC), the first international treaty to limit human climate interference.

Today, the UNFCCC still stands and has gained two new additions: the Kyoto Protocol (1997) and the Paris Climate Agreement (2015). UN countries created these two baby treaties to hold governments accountable for their UNFCCC promises. In effect, the Paris Climate Agreement has replaced the Kyoto Protocol with a more globally supported and less binding climate agreement.


Civil society is not only important but necessary life blood

Civil society organisations were much in presence at ICN2, but mostly they left somewhat dejected. They are actually key forces for any transformation of food and health, not least as advocates, scouts and public voices at multi-levels and multi-stages [42–44]. And they have an important role in creating the leverage and political will necessary for change and for challenging issues such as corporate power. Civil society organisations can help provide ‘policy space’ for political leaders to push framework change. At ICN2 it was only relatively late in the long preparatory process that civil society was invited to engage in the ICN2 process, and even that required a long process of negotiation between some leading civil society individuals and the FAO. Thankfully, in the end, civil society was given a place. More than 150 civil society organisations came together, from a wide range of backgrounds, countries and interests, to develop a declaration emphasising the need for meaningful governmental commitment and steps after ICN2 [45]. An open letter was presented to the heads of the WHO and FAO, supported by over 300 individuals, advocacy organisations and academics from around the world [46] which proposed a mechanism similar to the Framework Convention on Tobacco Control (FCTC) for food. This argued that a legal framework and policy coherence free from conflicts of interest is required at a global level if malnutrition in all its forms is actually to be achieved [47].

A consistent theme in and outside the halls for civil society organisations at ICN2 was: what would it take to get ‘step-change’, systems change, framework change? The metaphors varied but the sentiment did not. They felt that government public health agencies were too often on the back foot, in thrall to economic ministries, who are focused on righting the world’s economy by tightening expenditure, even though there is debate about whether this is short-sighted. The case for prevention of diet-related ill-health is surely overwhelming. It ought to be popular yet meets resistance. ICN2 was not therefore the time for health bodies to be deferential but strong they ought to be helping their populations live under conditions which maximise the chance of healthy lives.


At Harvard, the Bigger Concern of the Faculty Is the President's Management Style

CAMBRIDGE, Mass., Jan. 25 - Among Harvard's faculty, the underlying conversation right now is not about gender differences and the ability of women to succeed in math and science. It is about Lawrence H. Summers's ability to succeed as president of the university.

The uproar over Mr. Summers's remarks suggesting that innate gender differences might explain the lack of women in math and science careers comes against the backdrop of distress over his management style, which has been building since he took over three and a half years ago.

A dozen Harvard professors, as well as other educators associated with the university, said in interviews that for all his intellectual vigor and vision, Mr. Summers, a former Harvard economics professor, has created a reservoir of ill will with what they say is a pattern of humiliating faculty members in meetings, shutting down debate and dominating discussions. This ill will, they say, has helped fuel the fury on campus over what Mr. Summers initially said were meant to be provocative, off-the-record remarks at an academic conference here on Jan. 14.

"Larry is stimulating to argue with one on one and would be admirably controversial as a colleague," said Daniel S. Fisher, a Harvard professor of physics and applied physics, who has observed Mr. Summers in many meetings. "But with Larry as president, the rules are clear. For the president, it is fine to be provocative, but for faculty, serious questions and constructive dissent are squelched."

The support of the faculty is particularly important now, as Mr. Summers pushes ahead with his ambitious plans to expand the campus across the Charles River, revise the undergraduate curriculum, make Harvard pre-eminent in big science and bring more low-income students to the university. The many admirers of Mr. Summers say his brash style makes him just the person to lead Harvard into the future.

Steven Pinker, a star psychology professor who left the Massachusetts Institute of Technology for Harvard a year ago, called Mr. Summers a "refreshing" change from the "bland diplomats" that he said college presidents tend to be today.

"He does speak his mind," said Professor Pinker, whose work Mr. Summers is known to admire and which provided much of the foundation for the recent remarks about women. "He subscribes to the idea that ideas should be discussed. He enjoys stating his position forcefully. He enjoys a forceful rejoinder. He doesn't believe people should wilt under the pressure of a good argument."

But his critics say Mr. Summers puts his ego before the university and its academic values.

"He just dominates faculty meetings," said Mary C. Waters, the chairwoman of the sociology department, "There's no dialogue. You speak and then Larry responds."

Most professors who were interviewed refused to be identified, saying they were afraid of retribution from Mr. Summers. Those who did speak on the record took pains to mute their public criticism.

Mr. Summers spent much of last week apologizing for his remarks about women and science and declaring his intention to recruit more women as professors.

In an interview on Friday, Mr. Summers said his propensity to debate and challenge "sometimes leaves people thinking I'm resistant to their ideas when I am really trying to engage with their ideas." Asked if he thought he needed to adjust his style, he said, "I've learned from this experience."

Whatever anger and resentment he has stirred among the faculty, Mr. Summers appears to have the strong support of the Harvard Corporation's seven-member board, which includes him and his former mentor Robert E. Rubin, a former Treasury secretary.

"I think he is an outstanding president and he has a chance to be one of Harvard's greatest presidents," Mr. Rubin said. He added that he was unaware of widespread faculty discontent with the management style of Mr. Summers.

Mr. Summers, who was Treasury secretary under President Bill Clinton, was only a few months into the job when he got into a fight with Cornel West, a star of the Afro-American Studies department, over his scholarship, which resulted in Professor West's highly publicized departure for Princeton. ("Good morning, Mr. President, who have you insulted today?" Mr. Clinton said to Mr. Summers in a telephone conference call after the West incident.)

Several months later, invited to speak at a conference on globalization sponsored by the Harvard Graduate School of Education, Mr. Summers stunned many professors with his brusque dismissal of their views on the subject, saying those who voiced concern about the possible downside of globalization were naïve. At an early meeting with some 80 law school professors, Mr. Summers dismissed as stupid the reasoning behind a junior faculty member's suggestion about which departments might benefit by moving across the Charles River, to Allston, Mass., though he later apologized. Some professors who were present felt that Mr. Summers was dismissing the faculty member along with her suggestion. Professor Fisher and others cite many recent examples in which Mr. Summers has dismissed their views or questions, or put down their colleagues. Professor Waters said she and many other women on the faculty left a meeting with Mr. Summers in October feeling he had not understood their concerns over the sharp decline in the recruiting of tenured female faculty members. But Melissa Franklin, a physics professor who had spoken out at the meeting, said she felt encouraged afterward when Mr. Summers telephoned her to say he wanted to explore her concerns.

Mr. Summers's reputation had preceded him to Harvard, and was even the subject of discussion on the presidential search committee. "When Larry was being considered for president, his provocative manner and insensitivity to others was the major criticism raised by skeptics," said Howard Gardner, a professor of cognition at the Harvard education school and an expert on leadership.

Supporters like Mr. Rubin "gave assurances that heɽ gotten an education in Washington, that his rough edges had been smoothed," Professor Gardner said. "On the basis of what I have observed and heard from colleagues, I now believe, regrettably, that the supporters were expressing a hope rather than a reality."

Professor Gardner made a point of saying that in many ways he still considers Mr. Summers "an impressive leader," adding, "but I fear that his inability to anticipate the effects of his informal remarks -- both in terms of content and in terms of style -- could cripple his effectiveness."

His critics say that Mr. Summers brings a hierarchical management style that is especially ill-suited to Harvard, a decentralized institution where much of the power resides with the deans of the university's 10 separate schools and where many faculty members have their own large egos as well as lifetime appointments. A president, they say, needs diplomatic skills to persuade the faculty to support his initiatives and work out compromises.

"For me it's sad that Harvard isn't able to benefit from all the upside potential of Summers as a leader because he doesn't know what kind of organization he's operating in," said Theda Skocpol, a professor of government. "And he's often self-centered and discourages people around him." Professor Skocpol observed that Mr. Summers's advantages as a leader include his incisiveness and ability to "identify a problem and throw out challenges."

Mr. Summers has made no secret that he intends to shake up Harvard and that intimidation may sometimes be required. In a mostly admiring article in the British newspaper The Guardian in October, he is quoted as saying, "You know, sometimes fear does the work of reason."

Told that many faculty members had described him as a bully who squelches debate, Mr. Summers said the criticism was unjustified. "I've not, since I've been here, resisted a meeting or a discussion with any faculty member on the university," he said. "I've never suppressed anyone's views."

Told that many faculty members said he had created an atmosphere of intimidation, he said: "I'm really sorry if that's true. It's certainly not my intent."

Even his critics say Mr. Summers is highly accessible. He might insult someone in a meeting, they say, and then telephone afterward to apologize and solicit their views. The problem, his critics say, is that his confrontational style and tendency to criticize the ideas of faculty members in front of their colleagues requires an equally combative response. And, as president, he has the upper hand in the battle.

"If you come back at him and hold your own, you come out all right," said Everett Mendelsohn, who has been a Harvard professor of the history of science for 40 years. "I've done it on a number of occasions." But Professor Mendelsohn added that many of his colleagues, while no shrinking violets, nevertheless feel afraid to speak up.

Professor Waters says she is not afraid of Mr. Summers. But she said she stopped going to meetings of the faculty advisory committee for the search for the dean of Faculty of Arts and Sciences because she felt Mr. Summers was ignoring the faculty's views.


Methodology

In the following, we outline why a macroeconomic framework incorporating endogenous adjustment mechanisms is more appropriate than relying on the more common aggregation of individual earnings data. In a competitive economy, the wage is the marginal product of labor (i.e., the change in output that results from employing one additional unit of labor), which can be derived based on the aggregate production function. Owing to a decreasing marginal product of labor, earnings are lower for a given capital stock in a healthy economy without NCDs than in an economy with NCDs. Thus, multiplying the wage level with the number of workers lost tends to overestimate the output loss if one takes the earnings for those observed in the presence of NCDs. The output loss tends to be underestimated if one takes the earnings for the counterfactual case in which NCDs are eliminated. In a dynamic economy, the output loss lies somewhere in between these two estimates. So given that most studies use the earnings for those observed in the presence of NCDs, they tend to overestimate the loss whenever non-marginal variations in labor are present. In dynamic terms, individual-level studies disregard any changes to earnings as driven by productivity growth but more subtly also by changes in physical and human capital stocks. Finally, what earnings-based studies fail to account for is that in the absence of NCDs, the capital stock would be higher, which, in turn, would imply a higher level of earnings. Thus, in that sense they actually tend to underestimate the output loss. Any of these inaccuracies are avoided in our framework, as we directly calculate the output loss associated with the reduction in the supply of labor and capital due to the presence of NCDs.

The underlying macroeconomic approach (the World Health Organization’s EPIC framework, or Projecting the Economic Cost of Ill Health framework) was first developed based on the growth model of Solow [24] and applied to estimate NCDs’ worldwide economic burden [25]. Since its development, researchers have applied the EPIC framework to several countries including China and India [3, 22]. The advantage of EPIC is that it allows for economic adjustment mechanisms and accounts for physical capital and labor loss from mortality. Later the model was improved [26] and applied to Latin American countries, including Costa Rica, Jamaica, and Peru [27]. The framework in this study is based on a human capital–augmented production function, as in [28], that accounts for the effects of projected disease prevalence on physical and human capital. Unlike EPIC, which captures mortality effects only, our model also accounts for NCDs’ effects on aggregate output by reducing effective labor supply through morbidity and by reducing physical capital accumulation through higher health expenditures or treatment costs. Our framework also contributes by reflecting aggregate macroeconomic effects when the impact of NCDs varies by age and when age groups differ in (average) education and experience—dimensions of heterogeneity that so far have not been considered. Thus, previous studies may mis-estimate NCDs’ overall economic burden because they do not fully consider all the pathways. Our framework was first applied to East Asian countries, including China, Japan, and South Korea [23].

In applying the model, we first recognize that NCDs can affect the economy via effective labor supply due to mortality and morbidity. Disease-induced mortality reduces the population and hence the number of working-age individuals. At the same time, disease related impairments, chronic pain, and mental health conditions tend to reduce worker productivity, increase absenteeism, and induce earlier retirement. Indeed, for some diseases, such as mental health conditions, the morbidity effect exerts a stronger economic impact than the mortality effect. We also consider the age-specific average human capital of the labor force in this analysis because NCDs may disproportionately affect more experienced age groups. Finally, physical capital accumulation is reduced because public and private resources are diverted to finance treatment costs. The health-insured part of treatment costs, in turn, translates into higher private health insurance premiums and Medicare/Medicaid taxes. This reduces aggregate savings and hampers economy-wide physical capital accumulation.

Data sources

The GDP projections for the status quo scenario and the saving rate are taken from the World Bank’s database [29–31]. The mortality and morbidity data (i.e., years of life lost due to premature mortality (YLL) and the years lost due to disability (YLD)) are from the Global Burden of Disease Study [1]. We rely on the International Labour Organization for age-specific labor force projections [32], the Barro-Lee education database for age-specific data on average years of schooling [33], and a World Bank report for returns to schooling data [34]. We calculate human capital according to the Mincer equation [35] with parameters from [36]. The physical capital data and the capital income share are from the Penn World Tables [37, 38]. The S1 Appendix describes the parameter values and data sources used in the macroeconomic model in detail.

We obtain information on treatment costs and the disease-specific annual growth rates of medical expenditures from Dieleman et al. (2016) [19]. In this study, the spending estimates were adjusted to account for comorbidities. In our projections, we assume a fixed annual growth rate of the disease-specific per capita treatment costs to adjust for rising medical costs over time. The annual growth rate of the per capita treatment costs is calculated based on the average annual growth rate of the total treatment costs over 1996 to 2013 in [19], cleaned of population growth. Table 3 displays the estimates of the treatment costs per capita and their growth rates based on [19].