gINTELLIGENCER E C O M M E N D A T I O N S & G U I D E L I N E S

Youth Manifesto on Non-Communicable Diseases

Sandeep P. Kishore �,1, Karen R. Siegel �,1, Aria Ahmad –, Amina A. Aitsi-Selmi k,

Mohammed K. Ali §, Phillip Baker ', Sanjay Basu “, Asaf Bitton w, Gerald S. Bloomfield §,

Gene Bukhman w, Eleanor Emery �, Andrea B. Feigl w, Karen Grepin ¤, Mark D. Huffman ��,

Kiti Kajana ��, Shweta Khandelwal §§, Kavitha Kolappa ––, Chenhui Liu w, Naaznin Lokhandwala §§§,

Vishal Marwah kk, Modi Mwatsama '', Nicole Novak ““, Shantanu Nundy ww, Paul H. Park §,

Cristina Parsons Perez §§, Matthew R. Price ¤¤, Nikka Rapkin ���, Hester Rice ���, Ben Seligman §§§,

Sumit Shah –––, Joao da Silva “, Devi Sridhar kkk, David Stuckler w, Rajesh Vedanthan kk,

Justin Zaman k,''', The Young Professionals’ Chronic Disease Network

New York, NY, USA; Atlanta, GA, USA; Toronto, Canada; London, UK; Sydney, Australia; San Francisco,CA, USA; Boston, MA, USA; Durham, NC, USA; Chicago, IL, USA; Delhi, India; Baltimore, MA, USA;New Haven, CT, USA; New Jersey, NJ, USA; Palo Alto, CA, USA; Karachi, Pakistan; Lima, Peru; andOxford, UK

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Non-communicable diseases (NCDs), includingcancers, heart disease, chronic respiratory illnesses,diabetes mellitus, and mental disorders2, are lead-ing causes of mortality and morbidity globally. Alandmark publication by the World Health Orga-nization (WHO) in 2005 reported that these dis-eases caused 35 million deaths (60% of totalmortality) that year [1]. Despite many presump-tions to the contrary, NCDs are not exclusive toolder individuals; approximately one-third of glo-bal NCD deaths occur prematurely in individualsless than 60 years, leading to 20.5 million poten-tially productively years of life lost in Brazil,South, Africa, Russia, India, and China in 2000alone [2]. Moreover, 70% of global disability-ad-justed life-years (DALYs), a marker of morbidity,

From the � Weill Cornell Medical College, New York, NY, USA; �Emory

kUniversity College London, London, UK; §Rollins School of Public Healt

“University of California San Francisco, San Francisco, CA, USA; wHarvar

Center, Durham, NC, USA; ¤New York University, New York, NY, USA

USA; ��NCD Alliance, New York, NY, USA; §§Public Health Foundation

MA, USA; kkMount Sinai School of Medicine, New York, NY, USA; ''N

USA; wwUniversity of Chicago Medical Center, Chicago, IL, USA; §§Am

New Jersey, NJ, USA; ���International Cardiovascular Health Alliance, S

§§§Stanford University School of Medicine, Palo Alto, CA, USA; –––Indu

Scholar, Lima, Peru; and '''The George Institute for Global Health, Syd1 These authors contributed equally to this work. 2 Mental disorders acc

NCDs. Despite the disproportionate burden of disease they cause, mental i

89,000 psychiatrists serving Europe’s 879 million people and 1800 psychiatris

issue that contributes to and affects the outcomes of all NCDs and mental h

comprehensive NCD treatment programs.

are due to NCDs. These figures suggest thatNCDs are not only significantly reducing people’slongevity, but also their quality of life and capacityto work.

The burden of NCDs is neither distributedequally across the globe nor across age categories.Four out of five NCD deaths in 2005 occurred inlow- and middle-income countries (LMICs) [1].In these countries, nearly 44% of deaths due toNCDs occurred before the age of 60 years, com-pared to only 19% in high-income countries [3],and the risk of individuals between the ages of15–29 years dying from an NCD is 30% higher inLMIC than in high-income countries. Maternaland child health interventions and infectious dis-ease control programs have extended global life

University, Atlanta, GA, USA; –University of Toronto, Toronto, Canada;

h, Atlanda, CA, USA; 'Australia National University, Sydney, Australia;

d School of Public Health, Boston, MA, USA; §Duke University Medical

; ��Northwestern University Feinberg School of Medicine, Chicago, IL,

of India, Delhi, India; ––Johns Hopkins School of Medicine, Baltimore,

ational Heart Forum, London, UK; ““Yale University, New Haven, CT,

erican Cancer Society, New York, NY, USA; ¤¤Independent Consultant,

an Francisco, CA, USA; ���C3 Collaborating for Health, London, UK;

s Hospital, Karachi, Pakistan; kkkFogarty International Clinical Research

ney, Australia. Correspondence: S.P. Kishore (sunny.kishore@gmail.com)

ount for 28% of the disability-adjusted life years (DALYs) caused by all

llnesses receive scant attention – and resources – globally. There are only

ts serving Africa’s population of 702 million. Mental health is a crosscutting

ealth interventions should therefore be developed and integrated as part of

expectancies and helped to close the gap in lifeexpectancy between the richest and the poorestcountries over the past 50 years. However, withoutsignificant changes to address these contemporaryglobal health priorities, these gains may be obliter-ated and disparities may again widen [4].

While these statistics are sobering, effectivesolutions do exist and reversal of current NCDtrends is possible. Experience in high incomecountries has shown that CVD events and mortal-ity have reduced over the years, partly owing tomedical therapies, and partly to risk factor control[5,6]. Tobacco use; excess consumption of alcohol;consumption of foods high in fat, salt, and sugar;and inadequate physical activity are known tocause more than 50% of the NCD burden [1,7].These important lifestyle factors are modifiable,but are often difficult and complex to change.For instance, recent research shows that althoughmany countries have witnessed reductions in riskfactors over time, stark disparities between thehighest and lowest-income countries remain.The population’s exposure to these risk factors isinfluenced by a myriad of socioeconomic, cultural,political, and environmental forces that often lieoutside the formal health sector. In essence,addressing the NCD burden by designing andbuilding societies that enable people to increasecontrol over, and to improve, their own health,as outlined in the Ottawa Charter for Health Pro-motion 25 years ago [8], requires challenging andchanging the status quo.

At the same time, the power of ‘‘top-down’’approaches to affect the lives of millions mustbe employed. The 2011 UN General AssemblyHigh-Level Meeting offers a key opportunity tobegin such a change [9]. The Young ProfessionalsChronic Disease Network (YP-CDN) is a trans-national advocacy network of over 320 young pro-fessionals in 42 countries that aims to placeNCDs higher on the global health and develop-ment agenda. We, the innovative and inspiredyouth of today and potential global health leadersof tomorrow, want to help build the mechanismsto enable other young people and communitiesaround the world to have a role in global advocacyand the development of local solutions, settinginto motion a grassroots social movement to ad-dress the escalating burden of NCDs. As the glo-bal younger generation, we contribute the skill,capacity, capital and innovation that is necessaryto fully address the NCD issue. Here, we ask gov-ernments, civil society organizations, development

agencies, and the global public health communityat large to reduce the age-adjusted mortality anddisability adjusted life years (DALYs) due toNCDs by 20% over the next 10 years, as targetedby the WHO, to enhance the productivity of allcountries [1]. Specifically, we request that theUN representatives to the 2011 UN GeneralAssembly High-Level Meeting on NCDs andother key stakeholders consider the followingseven recommendations, which are the resultof extensive dialogue and discussion amongYP-CDN network members, and which focuson capturing the wide-ranging societal and life-course drivers of NCDs. Fig. 1 summarizes theserecommendations.

C H A N G I N G T H E S T A T U S Q U O

Re-frame NCDs as a barrier to development.NCDs drain LMICs economic resources contribut-ing to a widening poverty gap. The WHO estimatesthat cardiovascular disease and diabetes alone areestimated to reduce GDP between 1% and 5% inLMICs experiencing rapid economic growth [10].There is evidence that NCDs pose a significant bar-rier to the achievement of the Millennium Develop-ment Goals (MDGs), to the eradication of poverty,and to the social and economic development of allnations [11]. NCDs exacerbate pre-existing healthburdens in countries still dealing with high burdensof infectious diseases [12]. For example, people inLMICs are increasingly exposed to the widely avail-able, intensely marketed high-fat, -sugar, and -saltfoods, beverages and tobacco products. This avail-ability increases the risk of many NCDs such as dia-betes, cardiovascular disease, and cancers, whichhave been shown to, in turn, increase the risk ofinfectious diseases such as tuberculosis and pneumo-nia [13–15]. Parental smoking removes disposableincome otherwise used for household food availabil-ity, directly contributing to food insecurity and stun-ting in LMIC [16]. NCDs are both a cause andconsequence of poverty. We fully support theWHO in promoting the idea that, ‘‘non-communi-cable diseases are closely linked to global social andeconomic development’’ and have aligned our ownadvocacy efforts along these lines [7].

Accordingly, we must now strengthen NCDsurveillance capacity to provide rigorous, high-quality data to monitor trends and effectiveness ofinterventions and to identify vulnerable populationsand health disparities.

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Recommendations1.1 Governments, civil society organizations, develop-

ment agencies, and the global public health commu-nity at large should re-frame NCDs as a barrier todevelopment by explicitly including NCDs as a tar-get for ‘‘technical assistance, capacity building, pro-gram implementation, impact assessment ofdevelopmentprojects, funding, andotheractivities,’’as recommended by the Institute of Medicine [17].

1.2 Governments, civil society organizations, develop-ment agencies, and the global public health com-munity at large should expand the next round of

development targets beyond MDG-specific tar-gets to a combination of human and economicdevelopment goals that explicitly address primor-dial, primary, secondary, and tertiary preventionand the treatment of NCDs.

1.3 Governments should include NCDs and NCDrisk factor data collection across all age groups,including biospecimen sub-samples, as part ofcountry-level demographic health surveys tounderstand the current burden of NCDs andlong-term effects of NCDs and to provide morereliable future projections of the NCD burden.

Fig. 1. Stakeholders, levers of influence, and recommendations for action.

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F O C U S O N T H E S O C I A L D E T E R M I N A N T SO F H E A L T H A S T H E F O U N D A T I O N F O RN C D A C T I O N

Health outcomes are strongly influenced by the so-cial, physical and economic environments in whichpeople are born, grow, live, work and age, and re-ceive health care [18]. While individual responsi-bility is important, we must move beyond anotion that this is the most important determinantof health, or that individuals should self-regulate inthe absence of adequate governmental and interna-tional regulation. Individuals, especially the young,elderly, and vulnerable, live in an increasingly afflu-ent yet unequal world, confronted by an array of so-cial and economic factors that makes the healthychoices the most difficult.

These societal factors, most of which lie outsidethe traditional health sectors, are modifiablethrough broad-based action to restructure theworld in which we live and the food supply fromwhich we eat [5]. Relevant evidence-based, afford-able policy interventions are available to membercountries; sufficient political will and capacity arenow required to implement them. Global policesincluding the WHO Framework Convention onTobacco Control [19], the WHO Global Strategyon Diet, Physical Activity and Health [20], theWorld Bank NCD policy report [21], the DiseaseControl Priorities Project [22], the WHO GlobalStrategy to Reduce the Harmful Use of Alcoholand the WHO Commission on the Social Deter-minants of Health report [18] are ground-breakingcontributions to the understanding of these riskfactors and the understanding of cost-effectivenessand operational feasibility of interventions. Thesepolicy documents should serve as the foundationfor policy interventions.

Hence, governments and international actorsmust focus on the underlying conditions that createor determine health, by modifying and creatingnew forms of social and economic policy.

There are substantial gains to be made. For in-stance, research shows that implementing preven-tive measures can result in unprecedented success– in some instances reducing the risk of NCDincidence by more than 90% [23,24]. Whereas sickindividuals require individual care, sick popula-tions require transformative environmentalchanges to prevent the causes of disease incidence[25]. Such primordial prevention is vastly moreeffective at reducing population-level risk [5]

but requires the collective will of multiplestakeholders.

Changing the status quo is never easy. For in-stance, addressing the underlying societal driversof NCDs requires tackling, and ultimately chang-ing, current economic and production modalities.Many vested interests resist such changes, statingthat restricting the production of tobacco and sugarwill result in economic hardship for poor popula-tions; these arguments are overstated and oftensimply wrong. Stringent tobacco control policieshave been shown to have minimal negative (andmore often positive) impact on a country’s GNP,employment, tax revenue, and foreign trade bal-ance, despite tobacco industry rhetoric [26]. Argu-ments that limiting population level sugar intakewill harm LMIC sugar farmers are unsubstanti-ated. The global welfare gains from removing allsugar trade distortions that result from protection-ist trade policies in Japan, Western Europe, and theUnited States, are estimated to be as much as $4.7billion per year [27].

Recommendations2.1. Governments should implement programmes that

tackle the social determinants of NCDs with par-ticular reference to the following: access to infor-mation (disparities in awareness), lifestyle choices(disparities of accessing healthier options), thera-pies (access to primary health care services andessential medicines), and financing.

2.2. Governments should engage local, regional,national, and global communities in health-relatedpriority setting, ensuring fair representation fromall stakeholders, including civil society

2.3. Governments should adopt and adapt evidence-based global strategies developed by the WHOGlobal Strategy on Diet, Physical Activity andHealth [20] and the WHO Global Strategy toReduce the Harmful Use of Alcohol and otherprograms such as the Disease Control PrioritiesProject as the foundation of future evidence-informed policies to reduce the burden of NCDs.

2.4. All stakeholders should engage with the privatesector in reducing the amount of salt, sugar, andsaturated fat content in the food supply and shouldeliminate trans fats intake, with an emphasis onminimizing price shocks that disproportionatelyharm poor populations.

2.5. Governments should ratify and implement theFramework Convention on Tobacco Control inits entirety to reduce global tobacco consumptionby 30% in 10 years. Special commissions shouldbe instituted to target informal sector tobacco con-sumption practices.

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NCD risks develop across the life course: exposureto risk factors begin in utero and early childhood,continuing through to adulthood [28,29]. NCDshave been shown to directly affect children asyoung as 8 years old, who can develop obesity withconcomitant blood pressure and glucose derange-ments [30–34]. The nutrition and epidemiologicaltransition underway in many LMIC is exposingchildren to unprecedented levels of high energy,nutrient poor foods with consequential rises inchildhood obesity and type-2 diabetes mellitus.The health of the mother and child from pre-con-ception through to adolescence, therefore, is animportant determinant of adult health.

Many international and national laws, policiesand international institutions recognize the rightsof the child to adequate health, which are en-shrined in the UN Convention on the Rights ofthe Child [35]. Specifically, the Conventionacknowledges the rights of the child to play (i.e.participate in physical activity) (Article 31) andthe right of the child to be protected from ‘‘infor-mation and material injurious to his or her well-being, bearing in mind the provisions of articles13 and 18’’ (Article 17(e)), encouraging the devel-opment of appropriate guidelines for advertisingand marketing of unhealthy products. In many na-tions, those who are the least able to control theirconsumption behaviors or understand them –namely children – remain exposed to unprece-dented levels of advertising of unhealthy foods,beverages, and tobacco. Recognizing these rightsof the child to health, all countries should take ac-tions to implement the policies outlined in theWHO’s Marketing of Foods and Non-AlcoholicBeverages to Children (resolution WHA63.14).Special consideration should be given for cross-border advertising, which requires new formats ofsupranational codes and regulations.

Recommendations3.1. Governments should include ‘‘health across the

lifespan’’ as a central pillar of all policies (‘‘healthin all policies’’) to enhance the conditions andhealth system in which people are born, grow, livework, and age.

3.2. Governments, civil society organizations, develop-ment agencies, and the global public health com-munity at large should strengthen maternal andchild health programs to reduce maternal and infant

mortality rates by 75% as a means to assert womenand children’s health rights, with an emphasis onthe life course approach to policy development.

3.3. Governments and private sector actors shouldimplement recommendations from the WHOpolicy document, ‘‘Set of Recommendations onthe Marketing of Foods and Non-Alcoholic Bev-erages to Children’’ [36].

A U G M E N T C A P A C I T Y T H R O U G HI N T E R D I S C I P L I N A R Y E D U C A T I O N O FT H E F U T U R E P U B L I C H E A L T HW O R K F O R C E

The publication of the Welch-Rose report on pub-lic health and medical education at the turn of the20th century led to vital investments in publichealth and medical education to prepare a genera-tion to cope with the traditional plagues of infec-tious disease [37]. In the 21st century, a modernhealth workforce sensitive to interdisciplinarymethods needs to be familiar with the complex nat-ure of current health issues, including NCDs. Inaddition to expertise in public health, epidemiol-ogy, and medicine, the future health workforceneeds training in economics, international anddomestic law, and agriculture to effectively addressNCD policy issues ranging from comprehensive to-bacco control to climate change to food policies.Future health workforce also needs training in par-ticipatory approaches that will ensure the authenticparticipation of all stakeholders in the processes ofinitiative development, implementation, and evalu-ation. This training will guarantee that future ini-tiatives targeting NCDs have the broad buy-inthat they need to be appropriate, effective and sus-tainable. In this generation, a new investment intotackling the social determinants of health is nowneeded with the appropriate breadth and depth totrain global leaders who can think across coredisciplines.

Recommendations4.1. Governments and development agencies should

actively seek input from young professionals onglobal development issues to harness their energy,creativity and leadership and recognize their roleas a key partner in combating NCDs.

4.2. Governments should invest in health professionaleducation at the primary, secondary, undergradu-ate, graduate, and postgraduate level, stressing:(1) intellectual capital, (2) communication skills,and (3) cross-disciplinary networks.

4.3. Educational institutions should build leadershipcapacity in young professionals by developing

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and implementing cross-disciplinary and trans-national leadership programs that address NCDs.

4.4. The WHO and civil society should improve acces-sibility, affordability, and availability of globallevel internships, scholarships and other trainingopportunities for young people, particularly fortrainees from LMICs., in order to facilitatecross-pollination of ideas, enhance diplomacyand strengthening of international relationsthrough health, and acknowledge the increasinglyglobal world needs.

E N A B L E G L O B A L A C C E S S T O E S S E N T I A LD R U G S A N D H E A L T H T E C H N O L O G I E S

In all areas of the world, access to NCD preventionand treatment tools remains inadequate. The pro-posed amendments to the WHO EB128/Conf.Paper 10/Rev1 by Bangladesh and other countriesaccurately depict the need to ‘‘develop and imple-ment legal and policy tools, as appropriate, to en-sure access to affordable care and treatmentby ensuring availability of necessary diagnostictools and medical products including medicinesand other equipment for the diagnosis and treat-ment of NCDs’’. Health care systems must alsobe reoriented to deal with chronic conditions thatrequire a lifetime of care and follow-up.

Recommendations5.1. Governments should mandate generic substitution

of medicines and utilize compulsory licenses toreduce the cost of managing chronic diseases byexpanding global financing bodies like The GlobalFund and UNITAID for the provision of essentialNCD medicines and diagnostics.

5.2. The WHO should swiftly enable pre-qualificationfor the 34 NCD medicines in the WHO PrimaryEssential Medicines for NCDs (PEN).

5.3. Government finance and health ministries shouldsupport local supply chain management throughincreased accountability and incentives [38].

5.4. The WHO should survey the availability andfinancial cost of diagnosis and treatment of NCDs,including catastrophic health spending, amongWHO member states [39,40] and work with theWorld Bank and others to develop financial safetynets for populations in need.

5.5. National health ministers and international healthbodies should take action to reorient health sys-tems toward a diagonal approach that encompassesboth acute care, chronic care and follow-up; this isconsistent with Recommendation 4 on augment-ing capacity towards new methods of integrationand implementation.

A D O P T I N N O V A T I V E F U N D I N GM E C H A N I S M S A N D F I N A N C I N G F O R N C DP R E V E N T I O N A N D C O N T R O L

Cost-effective interventions for controlling manyNCDs exist and provide opportunity for substantialpublic health gains [41]. However, a serious lack ofNCD-specific financing hampers global and nationalefforts to expand programs. The high burden of pre-ventable diseases in poor countries and communitiescalls for strategic planning of investments acrosshealth and health-related sectors to promote devel-opment. Existing levels of health spending for NCDsin Member States, especially in LMICs, is insuffi-cient to implement cost-effective interventions [42].

Despite the growing literature describing theNCD epidemic in LMICs, NCDs have often beenignored by traditional global health funding mech-anisms [43,44]. Even countries that are less relianton external funds, such as India, Brazil, and Russia,continue to ignore or grossly under-fund NCDs,guided by international doctrine [45]. In 2007,2.3% of the $22 billion in global health funds wentto NCDs [46,47]. Approximately half of the fundsfor NCDs prevention and control came from pri-vate foundations or companies, rather than govern-ment and public bodies, despite causing 60% ofdeaths worldwide.

The rising burden of disease inflicted by NCDscan be described as a symptom of failed develop-ment approaches that promote unhealthy lifestylesand disease-specific programs. Innovative fundingmechanisms, such as earmarked excise taxes on softdrinks, tobacco, and alcohol, could be successfulstrategies to fund prevention programs whilstsimultaneously improving health through discour-aging consumption. The Thai Health PromotionFoundation, for example, has successfully imple-mented a sustainable funding model to supportNCD prevention, based on a 2% surcharge on alco-hol and tobacco. In the United States, numerousstates continue to consider, or are currently imple-menting, taxes on sugar-sweetened soft drinks toreduce their consumption [48–51].

Dichotomizing of disease funding by a subjec-tive view of need should end. Health policy andprovision should be built around a more holisticview of people and of the health system – able todeliver multiple services for multiple needs. Fur-ther, in a world of limited resources and a ‘‘zero-sum’’ game in which increasing allocations to onedisease category threatens the amount availablefor other disease priorities, funding need not –

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and should not – come solely from typical ‘‘globalhealth’’ funders. Rather, NCD prevention can berecognized as a co-benefit of actions and resourcesstemming from other global issues, such as climatechange and food security. Urban policies to reducegreenhouse gas emissions via promotion of walkingand cycling over motorized transport would simul-taneously increase physical activity levels. Similarly,agriculture and trade policies that support cropsubstitution from tobacco and toward productionof fruits, vegetables and whole-grains for humanconsumption could contribute to improved diets,which would in turn reduce risk of NCDs.

Recommendations6.1. Augment and align global health funding from

donor agencies, member countries and privateindustry with areas of greatest public health gains,as measured through estimated age-adjusted deathrates and DALYs.

6.2. Governments should identify regional- and coun-try-level secondary economic gains or losses frominterventions that impact NCDs, including inter-ventions outside the health system, in order toachieve a ‘‘health in all policies’’ policy as donein Finland.

6.3. Governments should introduce NCD Actionplans at the ministerial level including NCDs asa line-item in national budgets but also taking careto integrate NCD prevention and control intocurrent priorities.

6.4. Governments and international research andfunding bodies should direct more funds to trans-lation trials that can add externally valid evidenceto support extensive implementation of science-based findings into real-life settings.

D E V E L O P A C O M M O N , C O M M U N I T Y - L E DV I S I O N F O R E Q U I T A B L E G L O B A LD E V E L O P M E N T

We advocate for a new 21st century movement thatdistinguishes NCDs as a barrier to development.The complexities of our globalizing world, andthe widespread risk factors for NCDs, requireunprecedented adaptations to the structures of glo-bal and national level public health agencies. To as-sert public health and medicine as sociallytransformative disciplines, we must first transformthe very nature of public health – we must changethe status quo and empower communities to do thesame, look outside of the health sector, invest inand engage young people, and actively includeindividuals in the policy decisions that affect them,breaking down silos and enabling synergy via

simultaneous top-down and bottom-upapproaches.

There are a myriad of initiatives led by or di-rectly engaging community members that havesuccessfully improved the population’s health.One example comes from a group of communityhealth workers in rural Nepal who investigated asudden and mysterious increase in COPD amongwomen in their village, only to find that the causewas not tobacco smoking (as presumed by a groupof foreign medical doctors in the village at thetime) but by the coal-burning stoves they wereusing to cook food for their families [52]. Anotherexample comes from Community Interventions forHealth (CIH), a multinational program to imple-ment and evaluate community-based interventionsto prevent NCDs in China, India, and Mexico. Adistinguishing feature of CIH is that it involvescommunity-members directly in the design, imple-mentation, and evaluation of the interventions[53]. A final example of the importance of involv-ing community-members in public health initia-tives is Agita Sao Paulo, a community-based andcommunity-led intervention program that has suc-cessfully increased physical activity levels among 34million inhabitants in Sao Paulo, Brazil and hasbeen scaled up throughout Latin America andglobally [54].

Recommendations7.1. Governments, civil society, development agencies

and global public health organizations shouldempower and engage communities, particularlyyouth, to promote equitable access to educationand leadership.

7.2. Governments, development agencies, and globalhealth practitioners should incorporate the voiceof the empowered community in decision-making.

7.3. Governments, civil society, development agenciesand global health organizations should work toincrease local communities’ awareness of risk fac-tors for NCDs and their long term effects, therebyenabling individuals to take control of their ownhealth and amplifying the positive effects of soci-etal changes on health.

C O M M I T M E N T S F R O M T H E Y O U N GP R O F E S S I O N A L S ’ C H R O N I C D I S E A S EN E T W O R K

The YP-CDN recognizes the multitude of issues,concepts, approaches, definitions, and proposedsolutions related to NCDs. It is important to notethat our overall goal is not to transgress the

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autonomy and rights of choice by individuals.Rather, we advocate informing people aboutchoices and engaging both industry and govern-ment to adopt policies that offer choices that arecommensurate with better NCD health outcomes.While many of us work in disciplines outside ofthe traditional ‘‘global health’’ field, each of ushas a role to play and commits to being a globalhealth advocate by promoting and implementinga set of principles to approach the societal problemof NCDs. To spur action by global stakeholders,the YP-CDN members commit to:

1. Reframe NCDs as a barrier to development: lobbyingour specific governments, promoting NCD awarenesson university campuses around the world, and engag-ing our local communities in print and social mediaon the social drivers of the NCD epidemic. We willpromote the view that these diseases should not beviewed solely as ‘‘the fault’’ of the individual, but thatNCDs are societal problems that require societalsolutions.

2. Focus on social determinants of health as the founda-tion for NCD action: contributing to the develop-ment of a vision of a future society rooted in asocial determinants of health approach and to worktowards integrating the multitude of global agendas,including climate change and sanitation,

3. Assert the rights of the child and care across the life-span: performing research to create new knowledge torealize health gains across the life course, includinghow they relate to the rights of the child, and to sharecurrent research with governments to accelerateprogress.

4. Encourage interdisciplinary education of the publichealth workforce: lobbying our individual academicinstitutions to introduce lectures on the global burdenof disease, social determinants of health, and the rela-tion of NCDs to development priorities like the Mil-lennium Development Goals, and leveraginginterdisciplinary training opportunities to tackle thecomplexities of real-world implementation and inte-gration in our curricula.

5. Enable global access to essential drugs and healthtechnologies: monitoring the WHO Essential Medi-cines List (EML) concept including adding NCDmedicines to the EML, ensuring their listing innational EMLs; monitoring whether medicines makeit to shelf and partner with grassroots organizationsand Health Action International to prevent drugstockouts, and helping set up systems that satisfy agood balance of equity and efficiency

6. Adopt innovative funding mechanisms and financingfor NCD prevention and control: encouraging syner-gies and fostering dialogue between public health(clinical- and population-based) and related disci-plines, such as urban planning or agriculture, as well

as actively recruiting alternative, non-medical sourcesof revenue in partnership with our peers who work inthese disciplines.

7. Develop a common, community-led vision for equita-ble global development: contributing to the develop-ment of a highly skilled movement through peer-to-peer support and capitalize upon opportunitiesoffered by seniors in the field to develop intellectualcapital, influence, and cross-disciplinary networks.We will continue to use virtual communities (web2.0 technologies) to produce a dynamic and barrier-breaking health movement driven by a commonvision, and the development of YP-CDN Networkitself is an example of such a model.

C O N C L U S I O N S

We identify key proximal, upstream behavioral andenvironmental risks that are amenable to publicpolicy, community-based, and private sector– andwe must actively and sensibly engage these sectors.At the same time, critical distal risks (e.g. biochem-ical risks) linger that are amenable to medication,and we must ensure equitable access for all thatneed these through increased commitments to glo-bal access to essential drugs and diagnostics. Final-ly, awareness is the key that unlocks theeffectiveness of proximal and distal interventions– individuals and communities have a role in chal-lenging and changing the status quo on theirhealth. Youth and young professionals provide akey bridge and mobilizing force to do just this.

The 2011 UN General Assembly High-Levelmeeting offers a key opportunity to begin suchchanges [9]. Here, we the Young ProfessionalsChronic Disease Network (YP-CDN) request thatthe UN representatives to the 2011 UN GeneralAssembly High-Level Meeting on NCDs andother key stakeholders consider the following sevenrecommendations: (1) Reframe NCDs as a barrierto development, (2) Focus on social determinantsof health as the foundation for NCD action (3) As-sert the rights of the child and care across the life-span, (4) Encourage interdisciplinary education ofthe public health workforce, (5) Enable global ac-cess to essential drugs and health technologies,(6) Adopt innovative funding mechanisms andfinancing for NCD prevention and control, (7) De-velop a common, community-led vision for equita-ble global development. The healthy developmentand sustainability of our world depends on it.

The Manifesto on NCDs is statement affirmingNCDs as the social justice issue of our generationand detailing our recommendations to the United

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Nations representatives for the 2011 High LevelMeeting on NCDs: (1) Reframe NCDs as a barrierto development, (2) Focus on social determinantsof health as the foundation for NCD action (3) As-sert the rights of the child and care across the life-span, (4) Encourage interdisciplinary education ofthe public health workforce, (5) Enable global

access to essential drugs and health technologies,(6) Adopt innovative funding mechanisms andfinancing for NCD prevention and control, (7)Develop a common, community-led vision forequitable global development. The healthy devel-opment and sustainability of our world dependson it.

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