Sociologists Sridhar Venkatapuram and David Stuckler discuss how tensions within society are slowing down the process of combating disease worldwide.
We are driven by the notion that politics, especially global health politics, can be richer than the pursuit of self-interest of different actors through greater reflection on the ethical issues at stake."
Ever since a popular theory arose in the early-1970s (known as a theory of ’epidemiologic transition’), we have become used to thinking that a country’s burden of disease shifts from acute infectious diseases to long-term chronic conditions as it develops.
Over the past few decades, however, this theory has been countered by the occurrence of emerging and re-emerging infectious diseases in developed countries and the growing burden of non-communicable diseases (NCDs, such as cardiovascular disease, cancer, chronic lung diseases and diabetes) in developing and developed countries alike, as well as by the rapid acceleration in the movement of diseases and their causes across borders. While much global attention has been given to the rapid spread of infectious diseases, less attention has been given to the rising burden of chronic non-communicable diseases around the world.
To address the oversight of chronic diseases in the world’s development programmes, in September 2011 the United Nations (UN) General Assembly held a rare, special session on the prevention and control of NCDs. Such a high-level session on a health issue was held only once before, on HIV/AIDS in 2001. Partly motivated by the arguments that HIV/AIDS was not just a health crisis but also a threat to national security, 189 countries signed up to the Declaration of Commitment on HIV and AIDS. That event proved a turning point in the global response to HIV/AIDS epidemic. The High-Level Meeting (HLM) on NCDs aimed to create a similar turning point by galvanising an increased and coordinated global response to NCDs.
There are wide-ranging arguments for why governments and their leaders should care about the prevention and control of NCDs both within and outside their borders. The main case for action includes the identification of the health burden of NCDs; NCDs as threats to economic and social development; the cost-effectiveness and -savings produced by NCD interventions; and the recognition that addressing NCDs requires leadership and coordinated, multi-sectoral policies domestically and across countries.
However, as anyone familiar with making health policy or with high-level UN conferences will tell you, there are politics involved. In the case of a UN conference, by signing up to a declaration, governments make a global public commitment to what is stated in the declaration. And so, understandably, months of preparatory work is done developing a final conference document which hopefully has a coherent vision, reasoning, and action plan. The few final months before the NCD conference involved difficult negotiations between various representatives of governments and some non-governmental organisations regarding what concrete commitments were being asked of different governments and non-state actors as well as what will be, and importantly, will not be included in the final conference document.
In an article published in the Bulletin of the World Health Organization, we reviewed the regional declarations leading up to the HLM in September to identify areas of intersection and divergence. Our analysis identifies four ’ethical dilemmas’ facing Europe and the global community. We frame them as ethical dilemmas, in contrast to ’concerns’ or ’questions’, because underneath the politics and practical deliberations on what language to include and exclude in the final declaration and indeed, global response, lie different conflicting ethical principles. We are driven by the notion that politics, especially global health politics, can be richer than the pursuit of self-interest of different actors through greater reflection on the ethical issues at stake. These ethical dilemmas are not exhaustive or mutually exclusive. Without one general ethical theory that would organise and guide consistent reasoning through all of them, we identify them separately.
The four dilemmas we identified included:
Dilemma 1. Human rights approaches