Discussions over the draft "Moscow Declaration" began in earnest today (April 28), as Ministers of Health -- including HHS Secretary Kathleen Sibelius -- gathered in Moscow to begin the First Global Ministerial Conference on Healthy Lifestyles and Non C..., organized by the World Health Organization and the Russian Federation.
An early version of the Declaration, posted on the WHO's website on March 29, had much good language and some thoughtful approaches to the epidemic that is rapidly growing in intensity around the world. However, negotiators are now convening to discuss a new draft, produced by a drafting committee, and issued to member states on April 21, which omits several key aspects of the zero draft.
The Declaration will almost certainly undergo serious negotiations over the next 24 hours, when it is expected to be approved overwhelmingly and provide keys to where nations are headed for the upcoming UN High Level Session on NCDs, scheduled for September. However, the new draft Declaration's changes from the intial one have some advocates concerned. For example, the original draft had a reference to "providing patients with...palliative care" in preambular paragraph five, whereas the new version omits the reference.
Similarly, preambulatory paragraph eight, which formerly read "Recognize that a paradigm shift is an imperative in dealing with NCDs' challenges, and that NCDs are caused not only by biomedical factors but also by social, economic and environmental factors, emphasizing the necessity of an multifactoral, multisectoral approach to deal with NCDs" has been deleted entirely, perhaps providing less of a rationale for donors to act on the social determinants of NCDs.
Another change sure to arouse controversy arises in the "Rationale for Action" section, where paragraph five formerly included a reference to "other chronic diseases, including mental health and neuropsychiatric disorders, chronic infections, and injury." These disorders, especially concerning mental health, have been brought up repeatedly in regional consultations as well as in the Global Forum on NCDs held earlier this week where civil society members spoke out, and their omission will be noticed.
Perhaps most troubling of all, the new draft omits mention of disease management in multiple places. The resulting document, if not revised, reflects a strong emphasis on prevention, but has much weaker language on treatment and care than the previous version. As public health professionals have often noted, effective treatment for chronic illness involves a continuum of care, beginning with prevention and detection, and moving into treatment and care as appropriate.
As if to underscore the point, the new document omits entirely the reference in the original draft to "availability of quality essential medicines for NCDs..."
A particularly difficult-to-understand change occurs near the end of the document, where the original had discussed innovative financing mechanisms and the provision of development funds. The new version is far fuzzier, and leaves out mention of both of these critical tools, instead referring only to "Investigating means to identify and mobilize the necessary financial, human and technical resources at country level." One might think that nations with circumscribed budgets for international assistance and global health might want to encourage any and all thinking about innovative finance mechanisms, but this does not appear to be the case. The idea of leaving development funding out of the equation is potentially very disturbing.
Finally, the new version contains no references to tying progress on NCDs to the Millennium Development Goals (MDGs). Perhaps this reflects WHO Director General Margaret Chan's view that the MDG "train" has left the station, and that NCD target are "strong enough to stand on their own." Chan argues that WHO plans to monitor NCD progress regardless of whether they are incorporated into the MDGs (some advocates have noted that MDG 6 already includes a reference to "other illnesses" which might pertain to NCDs). She has also pointed out that the other MDGs have baselines that began in 2000, whereas the new NCD baseline dates only from 2008, just a scant seven years from the scheduled end of the MDGs. Nevertheless, the new version of the document does not even refer to the global targets.
All of this probably will change a great deal in the next 24 hours. And all delegations, including the strong US contingent, are receiving input not only from their members and capitols, but a plethora of civil society organizations and businesses with interests in NCDs. How will this work out? We'll know in 24 hours. However, advocates are hoping that this "once in a lifetime chance" to make a difference on the NCD epidemic produces as strong a document as possible to carry forward to New York and beyond.