American Cancer Society (ACS)
  • Date submitted: 1 Nov 2011
  • Stakeholder type: Major Group
  • Name: American Cancer Society (ACS)
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Placing Non-Communicable Diseases (NCDs) on the Agenda for Rio+20:

American Cancer Society Input for the United Nations Conferenceon Sustainable Development in Rio de Janeiro, 4-6 June 2012


As world leaders and experts meet to secure renewed political commitment for sustainable development, toassess progress to date, and to address new and emerging challenges it is imperative that attention is drawnto the topic of non-communicable diseases (NCDs) and their links to economic development and the environment. NCDs?cancer, cardiovascular diseases, respiratory diseases, and diabetes?have been increasingly acknowledged as a major health and economic development issue, and one of the most signiﬁcant emerging challenges to poverty eradication.

The magnitude of this threat has been recently acknowledged in the UN High Level Meeting on the Preventionand Control of NCDs and its resulting political declaration (September 2011). The importance of the NCD burden and its links to sustainable development and equity concerns were also highlighted by many memberstates, experts, and civil society representatives at the recent WHO Meeting on the Social Determinants ofHealth in Rio de Janeiro (October 2011).

The Global NCD Burden

NCDs are the leading causes of death in the world, accounting for 63% of global deaths1. The burden of NCDs is greatest in the developing world, with nearly 80% of NCD deaths occurring in low and middle incomecountries2. In addition, vulnerable and socially disadvantaged people in developing countries get sicker anddie sooner as a result of NCDs than people of higher socio-economic status3. Approximately half of all female deaths in low and middle countries are attributable to NCDs4. Among women ages 15-59 in low and middleincome countries, NCDs account for 37% of total deaths and 18.5% of the overall DALY burden (disabilityadjusted life years)5. Even in low income countries the percentage of female deaths attributable to NCDs(32.6%) far exceeds those attributed to maternal conditions (3.6%) and HIV/AIDs (6.3%)6.

Projected increases in NCD incidence and mortality are expected to be greatest in developing countries.Between 2010 and 2020, global NCD deaths are projected to increase by 15%. NCD growth is projected to behighest in the regions of Africa, South-East Asia and the Eastern Mediterranean, where between 2010 and2020 NCD deaths are projected to increase by over 20%7. The growth in cancer incidence by 2030 is projectedto be over twice as high in low income countries (82% growth) compared to high income countries (40%growth)8.

The increase in NCDs is shifting the global disease burden and placing what has been referred to as ?a tripledisease burden??infectious, non-communicable and pregnancy related conditions?on people and healthsystems in developing countries, thereby complicating our ability to ensure the right to health. In combination,these place a tremendous and escalating strain on resource-poor health systems.9 NCDs thus represent a major and growing socio-economic burden in the developing world, which places undue strain on communities and health systems and is a major contributor to poverty. In the Political Declaration of the recent UN High Level Meeting on the Prevention and Control of NCDs, which has been unanimously adopted byMember States, the link between NCDs and poverty is underscored, noting ?with grave concern the viciouscycle whereby NCDs and their risk factors worsen poverty, while poverty contributes to rising rates of NCDs,posing a threat to public health and economic and social development.?10

The NCD burden in the developing world is on the rise due to demographic factors and development-relatedchanges in lifestyle, nutrition, and behavior. Chief factors contributing to the NCD burden, its growth worldwide, and its increasing impact in developing countries include:

? Demographic changes (i.e., and aging population) due to the combination of increasing life expectancywith decreasing fertility rates11.

? Changes in diet, working patterns, and activity patterns12 as a result of economic development, urbanization, and globalization, that have increased exposure to major NCD risk factors (the most signiﬁcant of which are tobacco, obesity, physical inactivity, and excessive alcohol consumption)

Some of the main common NCD risk factors are increasing as a result of environmentally problematic economic development policies and practices. For example, increases in obesity, physical inactivity, and air pollution have been fostered by planning and transportation patterns in urban centers that have also promoted environmental degradation. Poor diet (i.e., ?overnutrition?) and obesity have also been fostered byenvironmentally unsound rural development practices that diminish the availability of fruits and vegetablesand undermine food security.

A major impact on the NCD burden can be made by through preventative measures to address the maincommon NCD risk factors and strengthen access to NCD treatment and management. For example the, globalcommunity has the knowledge and tools to prevent more than half of all new cancer cases and cancer deathsworldwide13. The WHO estimates that approximately 40% of worldwide cancer deaths can be prevented byimproving eating habits and physical activity, reducing tobacco use and alcohol consumption, and immunizingagainst viruses.

Health, NCDs, and Sustainable Development

The critical importance of health as a foundation of sustainable development has been widely acknowledged.Health and development are intimately interconnected, and environmentally problematic forms of economicdevelopment can result in severe environmental health and nutritional problems. The important links betweenhealth, the environment, socioeconomic disparities, and poverty are acknowledged in both Agenda 21 and theRio Declaration on Environment and Development. Within Agenda 21`s section on ?social and economic dimensions? (section I), health ﬁgures as a chief focus. Agenda 21 underscores the ?primary health needs ofthe world's population? as ?integral to the achievement of the goals of sustainable development and primaryenvironmental care.

In particular, Agenda 21 emphasizes ?preventive and curative health facilities, especially primary health careand maternal health care systems accessible to all? as a critical component of sustainable development14. Furthermore, Agenda 21 affirms that efforts to address health, environmental and socio-economic concernsrequire intersectoral actions?with a particular emphasis on preventative health measures?and that there is aneed to ?to coordinate the involvement of citizens, the health sector, the health-related sectors and relevant non-health sectors (business, social, educational and religious institutions) in solutions to health problems15?.

The Johannesburg Declaration on Sustainable Development (from the 2002 Earth Summit in Johannesburg,South Africa) reaffirms the central importance of health in sustainable development, stating in paragraph 19 that: ?We reaffirm our pledge to place particular focus on, and give priority attention to, the ﬁght against the worldwide conditions that pose severe threats to the sustainable development of our people, which include...endemic, communicable and chronic diseases, in particular HIV/AIDS, malaria and tuberculosis...?16

Despite the widespread acknowledgement of health as a critical foundation of sustainable development,attention to NCDs in particular has been minimal, overlooking the important links between NCD preventionand control and global sustainable economic development. Given that environmental degradation and NCDs share similar causes and solutions, inclusion of the NCD challenge as part of broader debates about sustainable development and green economies and in the outcome document adopted at Rio in 2012 isessential to ensure more sustainable approaches to economic development.

Summary Recommendations for Rio+20

The American Cancer society urges that the Rio+20 meeting and its outcomes document reinforce the centralimportance of health concerns in global sustainable development policies, strategies, and actions, and that theconception of health within sustainable development be broadened in a manner that holistically integratesNCDs and established health priorities (e.g., maternal and child health and communicable diseases) andencompasses health issues throughout the lifecycle, with a particular emphasis on the most vulnerable populations.

NCDs are a major component of future demographic, economic development, and environmental trendsglobally and it is critical that they part of the dialog, metrics, and policies of sustainable development. It is imperative that the potential synergies between NCD control and environmental concerns be incorporatedwithin the agenda of the Rio+20 meeting. In particular, we urge attention to the importance of NCD prevention and control for:

? Promoting, health, wellness, and poverty alleviation.

? Monitoring the impacts of development and providing evidence-based support for sustainable development.

? Strengthening strategies for multisectoral policy development and planning, thereby maximizing theirpotential for the effective promotion of health, the environment, and sustainable development.

? Developing rural development and agricultural policies that support food security, nutritional health,and environmental sustainability.

? Developing urban planning and transportation policies and plans that promote health, environmental,and economic goals.

? Developing policies and strategies for tobacco control that promote health and sustainable development.

Potential Synergies between NCD Control and Sustainable Development

Policies and actions for NCD control and environmental issues have the potential for important synergies.Some environmental policies may also pose health risks or tradeoffs (e.g., economic and agricultural policiesto promote biofuel production can undermine food security and nutrition if not properly designed) that needto be considered in formulating sustainable development policies17. Inclusion of NCDs in sustainable development discussions is important to better understand the links between health and the environment andto maximize potential synergies between environmental, health, and economic development policies.

NCD control can contribute to a variety of elements encompassed within the vision of sustainable development as articulated in Agenda 21, including: promoting food security as a component of sustainable agriculture,protecting and empowering vulnerable communities and groups (e.g., women) in decision making processes,giving attention to rapid urbanization, reducing health risks from environmental pollution and hazards,strengthening basic health care services for women and children, and promoting of health education andprovision of essential drugs, and the development and monitoring of health indicators for sustainable development.

More broadly, interventions for NCDs can contribute towards progress on the Millennium Development Goals(MDGs). For example, controlling NCDs will make progress towards ending poverty (MDG1) and it willpromote gender equity (MDG3) and child health (MDG4). Similarly, reducing adult death rates and disabilitypromotes economic growth and poverty reduction (MDG1); and, given that NCDs are the leading cause ofdeath for women in most countries, preventing NCDs promotes women?s health and empowerment (MDG3).NCD prevention efforts can also complement interventions to ensure environmental sustainability (MDG7)through promoting biodiversity-friendly, sustainable food production, limiting production of and exposure toair and water pollution, and limiting occupational exposure to toxic compounds, among other measures.

Below is a survey of some speciﬁc examples of potential synergies between NCDs and environmental concernsthat can contribute to the pursuit of the broader global objective of promoting sustainable development.

NCDs, Health, and Poverty Alleviation

? Improved prevention and control of NCDs diminishes the health and economic burden on vulnerablepopulations, thereby contributing to poverty alleviation and the promotion of sustainable development.Actions targeting NCDs also support other global health priorities (e.g., maternal and child health,communicable diseases) and are essential to health system strengthening. Improved NCD control willstrengthen healthcare systems in ways that will bolster interventions for all diseases and health conditions, including improving and strengthening: public health literacy, human resources, technicalcapacity, primary care capacity and delivery, diagnostic capacity, infrastructure for secondary andtertiary care, and procurement strategies for essential medications. Priority interventions for NCDs ? such as tobacco control and improved nutrition? would actually beneﬁt maternal and child health18 For example, reducing smoking and indoor air pollution decreases childhood illness. Improvements inhealth status and in the quality and accessibility of health care as a result of attention to NCDs areessential for addressing poverty alleviation and promoting sustainable development.

NCD Prevention and Sustainable Development

? Prevention of some of the major NCD risk factors (e.g., poor diet, nutrition, and lack of physicalactivity) can and should be addressed through sustainable development policies (e.g., policies aimed at food security, sustainable agriculture, sustainable transportation, and urban air pollution). Attention to NCDs within the framework of sustainable development provides important synergies between healthand environmental concerns, helping to provide evidence-based support for negative impacts of environmental policies as well as strengthening the potential outcomes of environmental policy andgovernance structures.

? Because of overlapping causes between health and environmental concerns, there are potential synergies between educational efforts for NCD prevention/awareness and environmental sustainability.

? The development and implementation of preventative health and wellness initiatives within governmentpolicies and the private sector contribute to a greener economy and avert placing unnecessary burdenson economic and health systems.

? Attention to NCDs can help improvement monitoring of impacts of sustainable development initiativesand the development of evidence-based policies and strategies for sustainable development. Agenda 2119 calls for taking into account demographic trends and factors as essential to formulating integrated national policies for environment and development. Attention to the causes and implications of the NCD burden is an indispensible component of the future demographic trends thatneeds to inform sustainable development policies and plans.

NCDs, the Environment, and Multisectoral Approaches to Sustainable Development

? Cross cutting measures are essential for promoting sustainable livelihoods and environmental protection. As is the case for environmental issues, addressing NCDs requires a multi-sectoral, whole-government approach. Addressing both of these issues, necessitates engaging ministries of health,environment, transportation, agriculture, ﬁnance, foreign affairs, and education?among others?and,therefore, integrated approaches to addressing both issues can be supportive of strengthened modelsfor effective multisectoral actions and institutional frameworks for sustainable development. Agenda 21 acknowledges the virtue of intersectoral approaches that integrate health and environmental concerns, asserting that the ?linkage of health, environmental and socio-economic improvements requires intersectoral efforts?.Particularly relevant is the inclusion of prevention programmes ratherthan relying solely on remediation and treatment.? The Political Declaration of the recent UN High Level Meeting on the Prevention and Control of NCDs includes a commitment to ?promote, establish orsupport and strengthen, by 2013, as appropriate multi-sectoral national policies and plans for theprevention and control of non-communicable diseases20.? Inclusion of environmental considerations as part of the process of developing these multisectoral policies and plans is fundamental to the promotion of health and sustainable development.

NCD Control and Rural Sustainable Development

? Integration of health and environmental concerns is critical in formulating rural development andagricultural policies aiming to promote food security, improved nutrition, and more environmentallysound land and resource use practices. Attention to the NCD issue can help strengthen support forsuch policies and potentially improve their impacts on health, wellbeing, and the economy. A recent report (Bringing Agriculture to the Table How Agriculture and Food Can Play a Role in PreventingChronic Disease) asserts that ?In the decades to come, the agriculture and food system will need tochange to meet the related challenges of rising demand, accessibility and affordability, and improvednutrition and health?, necessitating an ?integrated look at agriculture, food, nutrition, and the growingthreat of diet-related chronic diseases.? The threat of ?dual malnutrition? brought on by the rise ofNCDs needs to be acknowledged and integrated within agricultural and resource utilization policies inorder to make ?healthy foods more available and affordable to consumers at all income levels?, therebyfostering more sustainable economic development. The persistence of ?current trends in agriculturewould mean maintaining inequitable food distribution, unhealthy diets, unsustainable environmentalthreats, and unknown risks from climate change? 21 . Addressing NCDs requires a multisectoral response that engages agricultural and food productions sectors (among others) in support of healthobjectives22. In order promote sustainable development there is a need for integrated approaches to enhancing agricultural production, increasing food access, supporting healthy populations, and protecting the environment. A combined focus on health and the environment is important for developing ﬁscal policies and subsidies that more fully account for environmental and health externalities and maximize their potential for promoting sustainable development. For example, policyand market instruments to support small scale food producers and farming communities in order topromote food security and improved availability and access to nutritious foods need to be mindful ofboth under and over nutrition in order to effectively promote sustainable development23. Conversely,policies targeting the price, availability, and marketing of unhealthy foods need to be cognizant ofenvironmental concerns, ensuring that they do not foster unsustainable resource use practices andmaximizing their potential to be leveraged for the promotion of more environmentally sound resourceuse practices.

NCD Control, Urbanization, and Urban Green Development

? Agenda 21 underscores the importance of attention to rapid urbanization and calls for the need for?greater attention should be given to preparing for the needs, in particular of women and children, forimproved municipal management and local government.? It also highlights the links between urbandevelopment, poverty, inadequate diets, and environmental hazards and the importance of attention tourban health as an integral component of sustainable development. Furthermore, it the underscores the fact that in urban contexts ?many factors that affect human health are outside the health sector?, thus requiring coordinated actions to address urban health. Given the important links between urbanization and decreases in physical activity, impoverishment of diet, and air pollution, attention toNCD control is a critically important component of urban sustainable development policies and programs. For example, WHO?s Health in the Green Economy brief24?which highlights some potential synergies and tradeoffs between health and climate change policies and interventions?asserts that ?cycling, walking and using rapid transit/public transport can greatly enhance levels of physicalactivity, helping prevent a range of chronic diseases including cancer, heart disease and diabetes.?Green transportation initiatives provide an excellent example of synergies between health and environmental issues. Green urban planning and transportation policies (e.g., investment in andprovision of transport network space for pedestrian and bicycle infrastructure, and land use planningthat increases density and diversity of uses) can diminish risk factors for respiratory disease, cardiovascular diseases, cancer, diabetes, and obesity, through promoting physical activity and addressing air pollution25.

Tobacco Control and Sustainable Development

? Tobacco exposure is a risk factor for cancer, cardiovascular disease, respiratory diseases, diabetes, andother diseases, and tobacco-related deaths are the single most preventable cause of death in theworld, making it one of the most pressing global health priorities.

? The WHO FCTC (Framework Convention on Tobacco Control)?an international treaty which currentlyincludes 174 parties?emphasizes the importance of ?protection of the environment? (Article 18) as partof tobacco control efforts, calling for ?Combined health and environmental efforts to promote nutrition and food security to promote government policies promote corporate initiatives that are environmentally sound and promote health, including social responsibility initiatives, workplace initiatives, and business practices (e.g., food and beverage industry)?. The FCTC contains a mixture of demand and supply side interventions for tobacco control. Among the three supply side interventions is ?Provision of support for economically viable alternative activities?, including for tobacco workersand growers (Article 17). Supply side measures targeting tobacco cultivation can provideenvironmental beneﬁts (and health beneﬁts to rural workers) and need to incorporate a sustainabledevelopment framework in promoting alternative agricultural and land use programs.

? Increasing taxes on tobacco products is seen as one of the most effect ways to diminish demand and promote tobacco control26. Resources raised through these taxes can potentially be applied to supporting economically and environmentally sustainable alternative agricultural activities.

? Implementing comprehensive national tobacco control strategies also brings additional potential economic beneﬁts, thereby supporting sustainable development efforts. Smoke-free workplaces createa healthier workforce that beneﬁts businesses by reducing absenteeism, improving productivity, andlowering healthcare costs and Insurance premiums27. Secondhand smoke imposes a heavy ﬁnancialburden on businesses in the form of increased medical costs for employees, lost productivity due toillness, higher Insurance premiums, and other costs.28

1 World Health Organization. 2011. Global status report on noncommunicable diseases 2 Ibid. 3 Ibid. 4 NCD Alliance. 2011. Non-communicable Diseases: A priority for women?s health and development. 5 WHO. 2008. The global burden of disease: 2004 update. Geneva, World Health Organization. 6 Ibid. 7 WHO. 2011. Global status report on noncommunicable diseases. 8 World Health Organization. 2011. Global status report on noncommunicable diseases 9 Beaglehole et al. 2011. Priority actions for the non-communicable disease crisis. The Lancet 377 (9775): 1438 - 1447. 10 Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Noncommunicable

Diseases. 2011.

11 Raymond, Susan, Henry Greenberg, and Stephen Leeder. 2005. Beyond reproduction: Women?s health in today?s developing world.International Journal of Epidemiology 34. 12 PATH. 2009. The growing chronic disease burden: implications for reproductive health. Outlook 26(1). 13 American Cancer Society. 2011. Global Cancer Facts & Figures 2nd Edition. 14 Earth Summit Agenda 21. 1992. Available at: 15 Earth Summit Agenda 21. 1992. Available at: 16 The Johannesburg Declaration on Sustainable Development. 2002. Available at

17 World Health Organization. 2011.Health in the Green Economy Policy Brieﬁngs: Health Co-beneﬁts of Climate Change Mitigation. Available at 18 Beaglehole et al. Priority actions for the non-communicable disease crisis. The Lancet, Volume 377, Issue 9775, Pages 1438 - 1447, 23

April 2011. 19United Nations. 1992. Earth Summit Agenda 21. Available at: 20 Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Disease.


21 Nugent, Rachel. 2001 Bringing Agriculture to the Table How Agriculture and Food Can Play a Role in Preventing Chronic Disease. The Chicago Council. 22 Ibid. 23 Food and Agriculture Organization of the United Nations (FAO). 2011. Greening the Economy with Agriculture: Concept Note. 24 World Health Organization. 2011.Health in the Green Economy Policy Brieﬁngs: Health Co-beneﬁts of Climate Change Mitigation.

Available at 25 Ibid. 26 World Health Organization. 2004. Building blocks for tobacco control: a handbook. Geneva: World Health Organization 27 Reed H. 2010. The effects of increasing tobacco taxation: a cost beneﬁt and public ﬁnances analysis. London: Landman Economics for

Action on Smoking and Health.

28 Ross H. 2005. Economics of smoke-free policies. In, The SmokeFree Europe Partnership, Smoke free Europe makes economic sense: Areport on the economic aspects of Smoke free policies. May 2005. p13-17.ﬁles/SmokefreeEurope-102853A.pdf.
