Commentary: An NCD research agenda for WHO

ProCor is pleased to publish a commentary by Richard Horton, Editor of The Lancet and distinguished member of ProCor's International Advisory Board. The meeting to which he alludes in his article took place on 25-26 August 2008 in Geneva, Switzerland. In order to obtain global input on a prioritized research agenda for prevention and control of non-communicable diseases, Dr. Ala Alwan, Assistant Director General (NCD) of WHO and his staff convened 150 members from every part of the world, including donor agencies and experts from every sector of NCD (heart disease, stroke, cancer, diabetes, chronic respiratory disease, and genetics), and this was the first time technical experts from different NCD disciplines came together to address what is called an 'integrated approach to NCD prevention'.

After two days of intense discussion among the participants, Dr. Horton summarized the meeting in impromptu remarks that, in my view, produced the spark required for the NCD community to act. At my request, Dr. Horton kindly created a text version of his remarks and authorized its publication through ProCor. This is a 'must' read (and act) for all those involved in NCD. We are grateful to Dr. Horton for putting together this cogent text for the benefit of all those involved in NCD prevention.

Arun Chockalingam
Chair, International Advisory Board, ProCor Professor of Health Sciences, Simon Fraser University, British Columbia, Canada

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An NCD research agenda for WHO: Concluding remarks
Richard Horton
Editor, The Lancet
26 August 2008
Geneva, Switzerland

Our meeting to define priorities for an NCD research agenda proved to be two meetings. One was public, polite, optimistic, considered, and collegial. The other took place over coffee and in corridors and was more blunt, more critical, more sceptical. In the shadows of our public conversation, some of you wondered out loud what WHO could truly achieve through a gathering such as this.

The private debate needs to be brought out into the open. How will this group really make a difference? Can we deliver on the expectations set out in the global strategy for the prevention and control of NCDs? Remember: this strategy is time bound. It has to be achieved in five years, by 2013. So success will depend on unprecedented levels of collaboration. Can we do it?

I want to summarise our discussion - and add a few tangential thoughts - based on the framework laid out in WHO's research strategy, as presented by Tim Evans on Monday. This strategy matters. It matters because it has been devised and is owned by countries. This is the research strategy that countries want. It has five parts.

The first is priorities. Here there is much that we agree on. We need to look again at several definitions: asthma, type II diabetes, even the meaning of chronic disease (we must not exclude mental health; and AIDS is now a chronic disease). Is there a place for wider use of syndromes or phenotypes in our definition or characterisation of NCDs? Surveillance is also key: health information systems, registers, cohorts, databases, and standardised data across all of these means for strengthening our understanding about the burden of disease. Descriptive research can be extremely informative too - documented success and failures, economic analyses, and measures of wellbeing.

Evaluative research is critical, yet this area is highly contested. We agree that we need more implementation research, more studies of programmes, models of care, and behaviour. But we disagree on the role of randomised trials. Some of you are strongly for trials, others much more anxious that trials will not produce the kind of evidence we need to make progress. There is a false dichotomy here. Trials are necessary. They provide the most valid and reliable evidence for action. But trials do not preclude other, more qualitative methods. Anthony Costello's maternal and newborn community intervention trials are randomised comparisons, supplemented by detailed anthropological investigations to find out why certain actions work while others fail. Irrespective of the evaluation method, studies need to make sure that they can inform local practice and be useful to policymakers.

The second part of WHO's research strategy concerns capacity. We have recognised repeatedly the constraints in human resources for research systems. But I do not think we have been critical enough of research collaborations between high and low-middle income countries which sometimes amount to little more than exploitation of participants and theft of data, leaving no discernable benefit to the communities in which the research took place.

Still, there are several wonderful examples to draw on. Let me single out one: Srinath Reddy's Public Health Foundation of India, launched in March, 2006. The aim of the PHFI is to strengthen training, research, and policy development in public health; to encourage India to invest more in health, health information systems, and health research, and to devise a research agenda based on national priorities. The Foundation is a public-private partnership involving academia, government, and civil society. It's early days, but we should follow Srinath's work carefully. We have much to learn from examples such as his.

The third element in WHO's framework is standards. We need to hear more about enforcing standards. And again, research has a part to play here. Independent evaluation of health-systems reforms, such as those that took place in Mexico in 2000-2006, show that technical evidence is not enough to improve health. Evidence has to be socially acceptable. And garnering acceptability demands community and civil society engagement. So we need to hear more from civil society in devising an NCD research agenda. I was in Mexico City three weeks ago for the International AIDS Conference. It is inconceivable that Tony Fauci could set out a research agenda for AIDS without civil society input, debate, and provocation. The same should be the case for NCDs.

A fourth component of the WHO strategy is translation. There is a danger of making translation sound too easy. Research for health is the slogan for Bamako, for example. Three words. It's that simple! But the social science literature is full of work showing that translation is not only a technical task - packaging and delivering a set of interventions. Translation is also about understanding local values and customs, content and judgments. Taking account of this kind of complexity is not always comfortable. What we think are agreed assumptions may be challenged and questioned. So we need research about how research informs our understanding of health and illness, and the lives of people living in communities.

We also need to question the way we transmit the products of academic study. Journals are graveyards and ghettos for good ideas. Take just one example from The Lancet this week: a letter from Chinese scientists reporting how a 2002 paper in a seismology journal warned of the high probability of earthquakes in Sichuan province (1). That warning went unheeded. It did not get to policymakers. There was no mechanism for projecting that warning into a serious policy forum. Translation is not only difficult. It can be confusing. A recent paper in the Bulletin of the WHO reported the utter confusion among many at country and global levels about the meaning of translation (2).

Finally, the element underpinning priorities, capacity, standards, and translation is building a strong and sustainable research culture in our organisations and in countries. I am an enthusiastic outsider to the NCD community and I can see that it rightly wants to claim a place as a separate global health initiative. But at the same time, putting yourself in the position of a policymaker or a minister at country level, you would likely want to think about NCDs more broadly - as a missing dimension of the Millennium Development Goals, as a component of primary health care, or as part of a revitalised commitment to health equity (as set out by the Commission on Social Determinants for Health). So I hope we can ask how our research questions can help those in countries to make the best decisions for their health systems overall. These questions will take us to the edge of our experience and evidence: to urban design, the environment, and climate change.

But I want to end with two larger questions.

First, the question that occupied some of you outside this room: what can we reasonably expect WHO to do? In June in Divonne, Margaret Chan (WHO's Director-General) chaired a high-level consultation on scaling up research and learning for better health. WHO is extremely serious about its commitment to research. Why? Because the obstacles to achieving the health MDGs are proving hard to tear down. We need new ideas, not only for the MDGs but also for the wider objective of achieving the highest attainable standards of health beyond the MDGs.

So what did this external consultation of researchers from Africa, Asia, and Latin America, together with funders, ministers, and agencies, decide? That WHO has unique legitimacy through its intergovernmental role to coordinate, convene, advocate, and support work to advance health research. That WHO can be an independent technical bridge between donors and countries. That WHO must work with others - especially academic institutions - to evaluate programmes. That WHO is the voice of countries, through its country and regional offices. Several of you these past two days have said that you want WHO to take a stronger lead. And I'm sure WHO has heard your call. Pressure on WHO is not only coming from you, the NCD research community. The wide regional consultations that have taken place in advance of the November Bamako conference have revealed incredible energy around research. We have an obligation not to waste that energy.

A second question that we have barely touched on is how we are going to create a social movement for research to improve human health, especially NCDs. There are clues to answer this question, but they do not come from the biomedical community. They come from political science.

In October last year, The Lancet published work by a brilliant young political scientist working at Syracuse University in the US (3). Jeremy Shiffman looked at what makes some global health initiatives succeed - or fail. What determines what the world judges to be important? In other words, what do we need to do to succeed in advancing the case for NCDs.

We need actor power - that means all of you. Actor power means creating a network, or a network of networks, for all those working in NCDs - the Global Forum, COHRED, NIH, Wellcome Trust, Oxford Health Alliance, Ovations, and others. You need to cohere, to agree about what needs to be done. You need to identify fantastic, articulate, and respected leaders. You need to align your institutions and programmes behind those leaders and your agreed strategy. And you need to root all of this in a mass civil society mobilisation. If you do not believe me, look at Jim Grant when he was at UNICEF, or the AIDS community today.

We need to win the argument with ideas. But what is our key idea? Are NCDs another global health initiative? A development issue? A humanitarian crisis? Or a threat to security? We must get our frame of reference right so that it resonates for us and for those we are trying to persuade.

We need to understand the politics of global health. We have to be opportunistic. Is the time right for us? Are the global conditions favourable for us to make progress? They are favourable, but we can make them even more favourable by doing great science, convening the right people at the right events, and through advocacy - all tied to institutional leadership, nationally and globally.

And lastly, success will depend upon the characteristics of the issue - in our case, NCDs. Is the problem severe? Yes. Do we have cheap and effective solutions? Yes. Do we have credible indicators to measure our progress? Yes.

We have the building blocks of actor power, ideas, the right political moment, and the data to back up our claims. We need to refine each one of these. But what we cannot do is to continue on the same path as before. That way has failed. We have to do something different, radically different, we have to be more ambitious. We must support WHO given its unique political mandate and its renewed support for NCDs. And WHO has to support us, by redirecting more of its resources into NCDs.

I believe that we can renew our optimism and belief in ourselves. Each one of us has something to contribute. Let us leave today making a personal commitment not only to do more in our own roles, but also to do more to support a coordinated global response to what is a pressing human health emergency - the epidemic of non-communicable disease.

Citations:
1. Hu G. Sun Z. Poor knowledge translation: an urgent problem in China. Lancet 2008; 372: 718.
2. Cordero C, Delino R, Jeyaseelan L, et al. Funding agencies in low-and middle-income countries: support for knowledge translation. Bull WHO 2008; 86: 524-34.
3. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007; 370: 1370-79

Advocacy & Policy
Date Posted: 31 August 2008