NEW YORK CITY – A painstakingly negotiated Political Declaration on Noncommunicable Diseases with overwhelming support from UN member states failed to win formal endorsement at a special High Level Session of the General Assembly Thursday – after the United States torpedoed its adoption by consensus.

The last minute moves means that the draft declaration will have to face a vote in the GA – most likely next month, observers said. 

Dozens of presidents, prime ministers and health ministers, speaking on behalf of the world’s largest blocs of both developed and developing countries, hailed the draft, saying it should be approved immediately, at the Fourth UN High Level Meeting on NCDs and Mental Health.  

But in a blustery statement, US Health and Human Services Secretary Robert F Kennedy Jr charged that the UN draft went too far in recommending mesaures like taxes on unhealthy products – while not going far enough on other chronic disease related issues. The US veto means the draft must be submitted to a formal member state vote to be endorsed – since the declaration was supposed to be by consensus. 

“Throughout the course of the plenary segment today, we have listened intensively to the position of member states regarding the draft political declaration,” said the current UN GA president, Annalena Baerbock, a German diplomat.

“While I understand that there remain objections by some member states, there is also broad support for the text. The document will be considered by member states in the General Assembly,” Baerbock concluded.

RFK Jr – declaration ‘exceeds the UN’s proper role’

Addressing the High Level meeting,  Kennedy charged that the final draft text, “exceeds the UN’s proper role while ignoring the most pressing health issues, and that’s why the United States will reject it. 

“More specifically. We cannot accept language that pushes destructive gender ideology,” Kennedy said. “Neither can we accept claims of a constitutional or international right to abortion, the WHO cannot claim credibility or leadership until it undergoes radical reform. The United States objects to the political declaration of non communicable diseases. 

“The draft declaration should not have been included in today’s agenda,” Kennedy insisted, adding it was “filled with controversy with provisions about everything from taxes to … management by international bodies of communicable diseases.

Kennedy’s statement was paradoxical insofar as he has ostensibly made fighting chronic diseases, including risks like obesity an unhealthy foods a cornerstone of his Make America Healthy Again (MAHA) agenda. 

The final draft text also makes no reference to abortion, stating only that NCDs need to be mainstreamed into “sexual and reproductive health programmes.”

A single reference to gender calls for mainstreaming “a gender perspective” into NCD prevention and control – as a critical lens for understanding and addressing the health risks of women and men “of all ages.”

“The United States will walk away from the declaration,” Kennedy concluded. “But we will never walk away from the world or our commitment to end chronic disease. We stand ready to lead to partner to innovate with every nation committed to a healthier future.”

Overwhelming support by other member states

At the HLM meeting, the US role seemed to model anything but leadership.  The solid wall of statements by countries expressed support for the draft resolution as it was agreed to in early September.

Those included endorsements by:  the Group of 77 including China, the UN’s largest bloc representing 130 emerging economies; the Gulf Cooperation Council, representing a powerful group of Middle East oil-producing states; the Caricom alliance of Caribbean nations; the European Union; Pacific Island nations; and the Philippines, speaking on behalf of the Association of Southeast Asian Nations (ASEAN).  

The Philippines noted how it had deployed over 20,000 primary care providers to address NCDs and mental health at primary care level at a cost of about $518 million. “The investment case is clear. NCDs cost the Philippines $13.5 billion annually through the health care cost and productivity losses,” said Secretary of Health, Teodoro Herbosa. 

Suriname’s new President, Jennifer Simons, herself a physician, stressed the importance of addressing mental health – a theme echoed by many ministers as well as other heads of state and government. “Our people are more and more confronted with the impact of mental health challenges. They feel lonely, depressed and often isolated. We will have to pay attention to the risk of social media and screen time in general, on the mental health of our children,” Simons said, adding that countries like hers also face “an escalating race of unhealthy lifestyles, which causes, of course, obesity among children, and adults.”

“The U.S. seems to be trying to sabotage the process, but we don’t see how they can succeed at this point,” said Alison Cox of the NCD Alliance. “It is really shortsighted and reckless in the face of an urgent global crisis.”

Draft text is first political declaration to set clear NCD targets

The draft sets, for the first time ever, some defined, if modest, targets for combatting NCDs, stating that by 2030, there should be 150 million fewer people using tobacco; 150 million more people with hypertension under control and 150 million more people with access to mental health care. 

Those targets are still far removed from aspirations of UN Sustainable Development Goal 3.4, established a decade ago. SDG 3.4 called for a reduction of premature NCD deaths by one-third by 2030. Since then, the NCD burden has only grown larger and chronic diseases now represent 74% of premature deaths worldwide. 

The final draft also saw language supporting national taxes on unhealthy products, one of the most potent tools for prevention, watered down under industry pressures. That text now recommends that member states: “consider introducing or increasing taxes on tobacco and alcohol to support health objectives, in line with national circumstances.”

WHO’s role in combating NCDs affirmed

Over earlier US objections, the draft declaration refers to WHO in half a dozen sections, recognizing: “the key role of the World Health Organization as the directing and coordinating authority on international health in accordance with its Constitution to continue to support Member States through its normative and standard-setting work, provision of technical cooperation, assistance and policy advice, and the promotion of multisectoral and multistakeholder partnerships and dialogues.” 

WHO “Best Buys” for prevention and control of NCDs are also cited. The Best Buys are a package of 16 key interventions to prevent and address smoking, excessive alcohol use, physical inactivity and obesity, as well as cancer risks.

“The political declaration before you is the strongest yet with ambitious, measurable and achievable targets,” said WHO Director General Dr Tedros Adhanom Ghebreyesus, speaking at the opening of the meeting. 

The political declaration, the fourth such document since 2011, also marks the first time that mental health risks are extensively addressed as part of the NCD paradigm, Tedros pointed out.

“For the first time, mental health is fully integrated into a political declaration. “It’s about time, in this declaration, you’re committing to expanding access to services for mental health care, but brick by brick, we must also tear down the walls of stigma that keeps so many people trapped.”

The WHO Director General called upon countries to implement three measures in connection with combatting NCDs – more preventive measures; full integration of NCD diagnosis and care into primary healthcare systems; and more equitable access to medicines and treatments. 

“Health does not start in clinics and hospitals. It starts in homes, schools, streets and workplaces, in the food people eat, the products they consume, the water they drink, the air they breathe, and the conditions in which they live and work,” Tedros declared.  “So the number 1 [ask] should be addressing the root causes and helping people to lead a healthy life.

“Second, I ask all countries to integrate services for NCDs and mental health into primary health care at the foundation of universal health coverage.  

“Third, I ask all countries to deliver equity through access and accountability.  That means making essential medicines and technologies available and affordable to all with financing that reduces out of pocket payments or costs. 

Air pollution mentioned – but not its fossil fuel sources

The new declaration also mentions air pollution as a ‘fifth’ risk factor for NCDs – a position for which environmental health advocates have long argued. 

The text states that member states:  “recognize also that the main modifiable risk factors of noncommunicable diseases are tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity and air pollution and are largely preventable and require cross-sectoral actions;”

It also notes that an estimated 7 million people die prematurely every year from air pollution-related diseases – most of them NCDs. These include air pollution-related hypertension, heart and lung diseases, and cancers that develop as tiny air pollution particles travel through the bloodstream and into key organs of the body, including the brain. 

And the draft text recommends measures that can reduce air pollution and its related disease burden, including:  “clean, efficient, safe, accessible and expanded urban public transport options, and active mobility, such as walking and cycling;” as well as reduced open waste burning; more affordable clean cooking, heating and electricity generation; vehicle and industrial controls on pollutants, as well as reduced exposures, particularly for children, to lead and other hazardous chemicals. 

However, the declaration doesn’t go far enough on the sidesteps any reference to fossil fuels as a major source of health-harmful air pollutants, noted Jane Burston, CEO of the Clean Air Fund, and it makes no mention of the co-benefits that can be gained from reducing air pollutants – particularly for climate. 

“It’s like pledging to tackle smoking without mentioning tobacco,” Burston said of the omission, in an appearance at a side event Wednesday evening, organized by the civil society group, the NCD Alliance. “We need to acknowledge where it’s coming from.”

Added Norway’s Minister of International Development Åsmund Grøver Aukrust, “the declaration reflects also a challenging geopolitical climates. This has clearly influenced the outcome of these documents… We regret the removal of targets for taxes on tobacco, alcohol and sugar sweetened beverages. We must work harder to prevent the devastating consequences of climate change, air pollution and their impact on health. We must be clear on our commitment on air pollution. Let’s remind ourselves that 95 percentage of all premature death due to air pollution occur in low- and middle-income countries.”

US objections – not entirely a surprise

The US objections were not a complete surprise.  A 3 September memo to the president of the UN GA by the political declaration’s co-facilitators, Luxembourg and St. Vincent and the Grenadines, declared that the draft represents “the broadest possible consensus” – but not full agreement amongst all member states: 

“On 2 September, we were informed by one delegation that it is not able to join consensus despite all our collective efforts,” stated the letter, obtained by Health Policy Watch. “While there is no unanimity of views, it is our firm belief that the finalized version of the political declaration we are submitting to you adheres to the principle of consensus because it reflects a general agreement among the membership and garners the broadest possible political acceptance by Member States. It represents the broadest possible consensus.” 

Then, in an 18 September memo, the US Mission to the United Nations raised the issue again, saying, “the most recent draft of the political declaration has not been agreed by consensus in advance, and thus the conditions stipulated by the modalities resolution have not been met. Therefore, the draft political declaration should not be brought before the high-level meeting for approval.”

Speaking at the High Level Meeting, Ralph Gonsalves, Prime Minister of St. Vincent and Grenadines, which co-facilitated the negotiations, said: “We recognize that it is not perfect, but perfection is not the standard in multilateralism, nor is it the measure of progress. What we have is a declaration that is robust, comprehensive enough to provide the necessary catalyst for action, and reflects the broadest possible consensus.”

‘Birthday checkups’ and other country commitments

In public and informal fora around the High Level Meeting, member states talked about what they are alerady doing to combat the global NCD epidemic – from higher taxes on items like sugary drinks and tobacco, to training health care workers to screen ‘at risk’ populations.

“We didn’t want to call them mandatory checks, so we are calling them ‘birthday checks’,” quipped Bonanza Perwira Taihitu, Indonesia’s Deputy Director General for NCDs,  at a civil society event sponsored by the NCD Alliance on the evening before the High Level Meeting. The country’s drive to conduct health screenings for hypertension, high blood pressure and other NCDs, which began in February, has already reached 32 million people out of Indonesia’s population of some 280 million people, he said.

Indonesia is also investing heavily in new digital health systems, Taihitu added, echoing calls by industry forces to national health systems to expand their reach  “via health innovation systems” along with expanding Universal Health Coverage to combat the high cost of NCD diagnosis and treatment.

Meanwhile, Jeremy Farrar, WHO Assistant Director General said that while the politics around the declaration is regrettable, what really matters is the momentum being seen at the national level.

“Although we need to say nobody’s happy with it, everybody is moving forward,” Farrar said, looking at the glass half-full.  “And ultimately, does anybody in Ho Chi Minh City or Jakarta or London really care what’s in that declaration? What matters is what the governments now go back to do in their own jurisdiction, and that’s what really matters.”

Image Credits: Hush Naidoo Jade Photography/ Unsplash, WHO, PAHO, Janusz Walczak/ Unsplash, E. Fletcher/Health Policy Watch.