Sharing knowhow and joining forces towards Health for All
Alison Katz

Noncommunicable diseases: Caution in our involvement!

Feedback to editorial of MMI Network News, December 2010, "Noncommunicable diseases - let us get involved!" (Bettina Schwethelm)

Dear all, 

A strong word of caution in how we (as opposed to the international health establishment) approach this question. Below a preliminary critique of WHO’s reports* on non communicable diseases.

WHO’s reports present all kinds of statistics on selected risk factors for mortality and through careful and very particular presentation of data (and quite some misleading and/or vague formulations) are able to show that “the leading global risks for mortality in the world are high blood pressure, tobacco use, physical inactivity and overweight and obesity. . .  They affect countries across all income groups: high, middle and low.”

My concern is that such analyses are misleading and are intended to promote a particular agenda – which may not be ours.  It is however very much the agenda of the multimillion dollar medical equipment and pharmaceutical industry whose major interest is noncommunicable, chronic disease, which guarantees long term high profits from life-long, heavy treatments and colossally expensive and sophisticated diagnostic equipment.  But this agenda, in many ways, runs counter to progress towards working on the economic and social determinants of health, primary health care, Health for All  - and to almost everything that the People's Health Movement PHM stands for.

I will summarize my major criticisms in order to clarify in what way I think this report reinforces the neoliberal approach to health and is antithetical to PHM principles. I am not an epidemiologist but the flaws in these analyses seem to me to be flagrant.

  1. Most critically, by failing to specify age at death, WHO ignores the question of PREMATURE mortality. Surely, premature and/or avoidable mortality/morbidity is at the centre of our concerns. The message, especially through WHO’s press releases on these reports, is that poverty, and the diseases of poverty (and Social Determinants of Health) are no longer significant. Disease and death are due to irresponsible behaviours and (basically) we are all suffering and dying from the same things. Again the myth that people everywhere have the same relation to globalization.
  2. The risk factors presented are apples and oranges. We have for example, symptoms, indices, measures, behaviours and objective external conditions, all categorized as “risk factors”.  Underweight, high cholesterol, unsafe sex, urban pollution, low fruit and veg intake. Surely, the confusion and mixture of kinds of risk factors, invalidates rankings and comparisons. Furthermore, many risk factors are all related to another risk factor (eg blood pressure, is one risk factor but so are BMI, physical inactivity, high cholesterol, obesity, which all four contribute and/are related to high blood pressure). How then can they be ranked (or assessed separately) in any meaningful way?
  3. There is additional incoherence in that the 24 “risk” factors (not all of which are risks but are measures) have very different relationships to causality, whether distal or proximal, upstream or downstream. For example, to use “underweight” as a risk factor is odd. (And a tautology?). People weigh too little because they have inadequate access to food and in combination with other factors such as unclean water and no sanitation, they suffer multiple infections. Infections and poor diet together produce underweight. Overweight is not a sort of parallel polar opposite but the result of a different set of factors along a different dimension. One results in mortality in utero, in childhood, and contributes to premature mortality in adults and the other kills people mostly over the age of 50 or 60, but also in very respectable old age between 80 and 100.
  4. Invariably, the so called risk factor is merely a description of a state, or a symptom, or a measure, it is not in itself the risk. The real risk factor or root cause - upstream is ignored. Why “underweight”? What is this terminology hiding? Why is WHO no longer referring to mal and undernutrition. My criticism here relates to the political meaningfulness of the selected risk factors. WHO will retort that it is presenting facts. Well, two points: certain facts, with all their most significant aspects removed ARE NOT INTERESTING and have no implications for action for health. But WHO presents this report as a guide for action, for prioritizing.
  5. We would of course want to go beyond malnutrition, this is our interest in the Social Determinants of Health.  By way of example, let us look at “underweight” and what is the real risk factor that needs to be addressed. Well it is access to food, with everything that implies in terms of agricultural policy, food sovereignty, local production, local and national control of agricultural policy, land reform, so people can feed themselves.  Chronic diseases and industrialized food as a risk factor, chemical and radioactive pollution, are these not worth mentioning even in a report heavily biased towards rich country/so called lifestyle health problems?
  6. In a particularly dishonest section predictably on sexual and reproductive health, we read that “almost three quarters of the global burden of unsafe sex occurs in sub Saharan Africa”. (I will leave aside the fact that WHO itself (and UNAIDS) have conceded that sexual behaviour does NOT vary much between countries and regions, this document blithely states the opposite.) But what does the burden of unsafe sex mean? What it means is that all STIs including HIV are more prevalent, because detection, treatment, control are lacking, and there is a higher population pool of infected, untreated people, irrespective of their sexual behaviour or practice. The same sexual act “committed” in Africa and in Europe carries a very different risk. As usual, the blunt message is AIDS/Africans/irresponsible sexual behaviour. Imprecise, unscientific, utterly unhelpful. 
  7. In addition, the report refers to burdens of disease but practically never in proportion to the size of the population. Comparable percentages of people (for example without access to clean water) are required. And this is particularly so when the victim blaming mode predominates - as is the case. 
  8. The choice of risk factors, WHO says, is determined by information being available. Two points: if data and evidence are not available on factors that are acknowledged to be important, then surely, this also invalidates any ranking of their respective contributions. How can these 24 risk factors be qualified as THE major risk factors, when it is conceded that other significant factors have not been examined for lack of data?  Two, we do have data for the REAL major risk factors. the big infectious killers, water and sanitation, hunger and its causes, environmental pollution/devastation. Why were they NOT selected for analysis of their contribution?
  9. Just one more example. A paragraph on health risks associated with climate change, fails to mention the most significant which is drought and flooding and the consequent reduction of usable agricultural land, low yields etc. Was this report seen and approved by the appropriate department (Environmental Health)?

As tax payers and citizens of the world, we have the right to expect rigour and meticulous analysis from WHO. The 2009 report is a rehash of the 2004 report, 15% of the references are to that report, and about 25% to documents written by Murray and Lopez. Have there been no developments in this area since then? I say that because there were many, serious critiques of these approaches even then.

If we, in PHM, do get involved in this effort,  let’s get some of our own epidemiologists to look very carefully at the epidemiology, just as a start and then look very carefully at the possible interests behind it, to ensure that our own approach is in line with social justice principles. 

In solidarity, Alison Katz

*Global health Risks 2009 and the 2004 report on chronic diseases

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