Addressing the Chronic Disease Crisis in Developing Countries

Task Force Co-Chairs Mitchell E. Daniels Jr. and Thomas E. Donilon, and Task Force Project Director Thomas J. Bollyky, join Time Magazine Senior Correspondent Massimo F.T. Calabresi to discuss the CFR-sponsored Independent Task Force Report on Noncommunicable Diseases (NCDs), which assesses the NCD crisis in developing countries and recommends practical, scalable strategies for intervention. Poverty and urbanization are contributing to the rise of NCDs like cancer and diabetes, and although NCDs are judged by the World Economic Forum to be the main threat to economic development after climate change and pose risks to global security, the United States spends 0.1 percent of its health budget on the issue. The panel discusses findings from its data-driven report and offers policy recommendations ranging from low-cost drug interventions to creating a U.S. strategy on NCDs.

CALABRESI: Hello, welcome. Welcome to today's Council on Foreign Relations meeting marking the launch of the task force report on noncommunicable diseases. This meeting, unlike many at the Council, is on-the-record. Joining me to discuss the report, we are fortunate to have its co-chairs, Mitch Daniels and Tom Donilon, and the project's director, Tom Bollyky, all of whom you know well.

Mitch Daniels has a long career in public service serving as Indiana's governor for two terms, starting in 2004, and is currently the president of Purdue University. Tom Donilon, also a long-storied career in public service, which culminated with his years as President Barack Obama's national security advisor. And Tom Bollyky is the Council's senior fellow for global health, economics and development, and formerly worked at the Office of the U.S. Trade Representative and at the Department of Health and Human Services.

We'll start, as always, with a conversation with the speakers and then move to your questions. The usual reminders: Please turn off your cellphones.

One of the Council's great strengths is that, in addition to weighing in with expert voices on the most high-profile international issues of the day, it also looks to shed light on undercovered, surprising, important issues for U.S. foreign policy, and that's -- this task force report is a very good example of that.

The report says in its opening lines, "The biggest global health crisis in low- and middle-income countries is not the one you might think. It is cancer, cardiovascular disease, diabetes, and other noncommunicable diseases," NCDs, "which killed more than 8 million people before their 60th birthdays in low- and middle-income countries in 2013 alone."

The other thing to note about this report is that it is very practical-minded. It is specific about recommendations and very clear about commonsense and cost-efficient ways to address what is a sort of unrecognized national security issue and foreign policy issue for the U.S.

So without further ado, to elaborate on that point, Tom, let's start. Why is the Council interested in noncommunicable diseases like cardiovascular disease and diabetes in the developing world?

DONILON: Thank you, Massimo. It's great to be here today, and we've had -- really had a terrific task force, I think, and -- and Mitch will talk a little bit about some of the -- some of the discussions that we had leading to these conclusions, but I will tell you that the initial discussions we had as a task force were around that very issue. What is the U.S. interest here? What is the U.S. strategic and security interest in a global -- in a health issue? And this is the first -- I think the first task force on global health that the Council on Foreign Relations has ever done. And the answer that we came to...

CALABRESI: Which is worth remarking on. It's the first report on a global health issue that the Council has ever done.

DONILON: Right, yeah. And it -- let's start with the scale of the issue. It is the principal health threat to low- and moderate-income countries in the world. It's a threat because of its nature that will only grow and become more difficult and become exacerbated. The scale is really tremendous. I mean, the World Economic Forum estimates -- and it stated -- that in its judgment, next to climate change, this is the principal threat to world economic development.

They also estimate -- they put a number on it -- which is cited in our report, which is they estimate that by 2030 the losses due to NCDs could approach $21 trillion or $22 trillion, which is the total output of these countries, I think, last year in 2013.

This obviously leads to a number of concerns of the United States. The United States also is the long-time existing global leader in health in the world, but from a strategic perspective, from the perspective that I would look at it from my former perch as national security adviser, it has, you know, absolutely clear impact going forward on the long-term economic stability of these countries, on their stability generally, on their governments, on their militaries.

It also -- because of its nature -- has the prospect of undercutting a lot of our existing programs and development and health programs. We have invested a lot over the last decade in communicable diseases focused on HIV-AIDS and made tremendous progress and made a tremendous contribution to the world.

The very same populations who are saved through those efforts are at risk through this threat. And it makes no -- really, very little sense in our assessment to have undermined the very efforts that we have underway. And also -- and I'll finish on another point before we -- we can go into this in great detail with respect to kind of its long-term -- the long-term threat here and the long-term interest the United States has in not seeing it become the kind of threat that it could become, it also is a really important opportunity for collaboration between the United States and some other major countries in the world, especially countries like China and Brazil, where we are really looking for ways to collaborate on addressing -- on addressing global and transnational issues.

So for all those reasons, our task force came to the conclusion that, in fact, it was a very important issue for the Council on Foreign Relations. I certainly -- we had another national security adviser on our -- former national security adviser on our team, on the task force, Sandy Berger, came to the conclusion -- and indicated to the task force -- our judgment that if we were still national security adviser, we would clearly see this as a national security threat and one that should be addressed in the interests of the United States.

CALABRESI: Well, another thing that in speaking with you all about the task force prior to the report, as task force, it became clear that this was not what in Washington sometimes happens, which is a group of people are named and they're -- and the next thing they hear or see is a report lands on their desk and they read it quickly and sign off on it.

This was clearly something of a discussion from the start. And I think it adds to the understanding of the final product, if we talk a little bit about that. So, Governor Daniels, tell us a little bit about where you came in on this project and how the conversation developed.

DANIELS: All that's true, to say the least. As Tom said, we came to the conclusion -- we didn't start with the conclusion -- quite the contrary -- I think this report is -- this was my first opportunity to take part in a CFR project, but I've been a part of many similar ones. And this one -- by the time it was over -- I thought was distinctive for a second set of reasons that your question surfaces.

I mean, first it was distinctive because first time, as you mentioned, that the Council's even looked at the issue of health -- global health, but to me, this report strengthened as it went along, through the work of our colleagues, who did -- many of them, I confess to having been one at the outset -- start somewhat skeptically. Is this as big a deal as it is being suggested? Even if it is, does it really engage the United States national interest to the extent that warrants the work we're going to do? We did ultimately conclude, as Tom just pointed out, the answer to those questions was emphatically in the affirmative.

But then I think the thing that I want to pay tribute to our colleagues about is that, at least in contrast with many that I've been part of or read, this is a very data-driven report. That was insisted on by many of our colleagues. You'll find more factual content than in many such reports.

It also -- I would contend -- is far more specific and actionable and realistic in its suggestions. It did not fall prey to the common tendency to let every cook throw his or her preferred vegetable in the stew, until in the end what you have is something that says everything and says -- therefore says very little. And the immediate short-term suggestions that are made are highly practical and affordable, not unimportant in this situation.

Lastly, it I think speaks candidly to the question of resource prioritization. One thing governments aren't very good at is rotating resources in a nimble way, as circumstances evolve. And while we don't prescribe any level of this or that, we do point out the rather stunning opportunity that's here in a situation in which the U.S., which is only spending 0.2 percent of its budget on the whole global health picture, is only spending a little over 0.1 percent of that on NCDs.

And so there's -- between an actionable set of options and the fact that we're starting from essentially zero, a real difference could be made. A detectable difference could be made in a reasonably short period of time, if these ideas were taken seriously.

CALABRESI: OK. So I'm sure that we will have from the audience very probing and hard questions. Let me start off with one or two of my own. Isn't this a high-class, first-world problem, heart disease, smoking? Why are we making other people's health choices our budgetary priority?

BOLLYKY: Great. Well, first, before I answer that, I want to thank the co-chairs for their service on this task force. They really did a remarkable job. This is not an easy issue in general. It's not one with which -- many of the task force members might have been familiar with beforehand, so they did a really fantastic job shepherding this through the process, and I want to acknowledge that.

Also want to acknowledge we have some task force members here in the audience, Secretary Glickman, Binta Brown, and Jean-Paul Chretien. I want to thank them also for their involvement in this process. The last bit of thanks -- and then I'll move onto your great question -- is, this report is really data-driven. Many of our task force reports may not necessarily include footnotes. This has really thirty figures. It's been very -- both what the problem looks like, how these diseases present themselves in developing countries and what the solutions were. We did this all through data, and we did that for the reasons that the chair has identified, which was that people needed to be convinced that this was a problem and that there were solutions out there.

And on the data front, I want to acknowledge Chris Murray and his colleagues, Joe Dieleman and Tara Templin, who worked with us through the Global Burden of Disease Report, which provided a lot, if not most of the data, and they really did a fantastic job. So I want to acknowledge that.

To your great question, is this an issue of the world succumbing to couch potato syndrome, and smoking at home, drinking, moving to more unhealthy lifestyles, making use of the increasing incomes in these settings, and the fact that we've made some progress on infectious diseases?

And what you can find in the report is a very clear case made that absolutely the fact that people aren't dying in childhood and adolescence of the plagues and parasites that they used to has something to do with the rise of NCDs, but only partially. What that doesn't explain is why people are getting them so much faster, so much younger, and with such worse outcomes than they did in high-income countries. That's the first part.

The second is that you might be surprised. The higher rates of cancer, diabetes, cardiovascular disease are actually in lower-income populations, just as they are here in the United States, and there's pretty strong evidence in the report on that in low- and middle-income countries.

And the last point I would make is that while certainly obesity is rising in these countries, it's still incredibly low. You're talking about adult obesity rates of 5 percent in low-income countries, maybe 7 percent low- and middle-income countries. In the U.S., it's over a third.

Many more multiples. These countries' problems aren't necessarily the same that we have here, and that's part of the reason why we did a -- we looked specifically at low- and middle-income countries, instead of tackling the problems of NCDs globally, because what's happening in these countries is different.

CALABRESI: But if it's partly couch potato syndrome and they're getting wealthier, what are the other drivers?

BOLLYKY: So it's partly about they're living longer. I'm not sure how much of the couch potato syndrome they have. But it's...

CALABRESI: They can get ill from cancer or cardiovascular disease because they're living long enough to enter the age range where those diseases tend to strike?

BOLLYKY: Right. Immortality remains elusive. We all must die of something. It's...

CALABRESI: As a smoking friend of mine used to say, "You'll die healthier than I will."

BOLLYKY: Yeah. But it matters when. And what's surprising about these diseases in these countries how many people fifty-nine and younger are getting them. We looked at the burden in the forty-nine countries that the U.S. invests $5 million or more in, and NCDs represent the largest source of premature death and disability in those countries, and not much of our current investment. What's driving these things? Persistent poverty...

CALABRESI: Urbanization?

BOLLYKY: ...urbanization, to some degree. These countries are investing, improving their health care systems, but their spending is still really low. Health spending in low- and middle-income countries tripled over the last twenty years, but all of the governments of sub-Saharan Africa spend as much as the government of Poland on their health care. If you add all low- and middle-income countries together, which represent 5.7 billion people, they spend as much as United Kingdom, as Germany and France and Canada combined, representing 250 million people. It gives you a sense of the disparities involved.

So, increase in risk factors from urbanization, the fact that these countries don't have established health systems make it more likely that they'll develop a noncommunicable disease like cancer, cardiovascular disease, younger. And the fact that there isn't the availability of chronic care and that the people remain still too poor to purchase these services out of pocket means they're more likely to become disabled or die as a result.

DANIELS: Just to follow that a little bit, there is no question -- it seems to me -- that a twenty-three year increase in global life expectancy over six decades plays a significant role, but it is so far from the complete explanation that some might have speculated. And Tom just gave you most of the reasons why.

I mean, I think what struck me was that it is striking so heavily at the middle-age, middle-class, where there is a reasonable middle-class, classes of these societies on whom they largely will depend if they're going to rise and surmount the problems he just talked about.

And again, I'd like to go back to the fact, we can't -- I don't think -- the report doesn't pretend that the U.S. or even a consortium of countries can build public health infrastructures and things where there aren't any, but anti-hypertensives are available at literally pennies per day. Vaccines, a hepatitis B vaccine that would prevent liver cancer in large numbers, likewise inexpensive. Likewise, the vaccine for cervical cancer, and that's exactly why the panel members pushed the staff to search the data for those sort of interventions. And you could make a real difference decades before these macro conditions come around.

CALABRESI: So let's break that down a little bit, because it's a good thing to follow up on. The report does break into three different categories, the remedies and the actions that the U.S. can take, immediate and high-impact, soon and high-impact, and long-term collaborative. What exactly are you recommending that the U.S. do? And how did you break it into those three categories? Do you want to...Tom?

BOLLYKY: So we put them in three categories. There are the interventions that are largely shovel-ready. In the same way that with the ramp-up of the response to HIV-AIDS, they looked at the things that could immediately be put out at that time, which are antiretrovirals. We're looking at this crisis and saying, well, what can be done now?

And one of the things you realize when you look at the data is that despite much higher rates of obesity and unhealthier habits, we've had dramatic declines in premature mortality in the U.S. and in other high-income countries. A lot of that is driven by really cheap interventions, so just to rattle a few in this first category: hypertension control, primary and secondary prevention of heart attacks, most importantly, tobacco control, which is not only cheap, but revenue-generating. Vaccinations for cervical cancer and liver cancer, which do not have the distribution that they need to. So that's the first category.

The second category are things that exist that we put in good -- put to good use in this country, particularly a lot of cancers. We've done a very nice job of reducing premature mortality from them, whether it's breast cancer or leukemia, stomach cancer.

Some of the interventions for this need adaptation. It's still really expensive to do mammography and resource-intensive to do that type of diagnostic work in a lot of low- and middle-income countries. Radiation services are not necessarily available. We need to do a better job of adapting these existing tools for use in a low-resource setting.

And the last thing -- and we were -- the committee was very adamant about making sure we covered this -- is the U.S. certainly doesn't have all the answers to noncommunicable diseases. We do have an enormous obesity problem. As Secretary Glickman kept us honest throughout this process, we have lots of nutrition issues in this country. There's a range of problems that we have that we don't know the answer to, these countries may not know the answer to, and the possibility of working together to develop those is something we should do. That's the third basket.

DONILON: Let me follow up on a couple things. I think, you know, in the first instance, of course, the task force calls on the United States to have a focused strategy and effort here, which it doesn't have right now. We have not as a government, with respect to our international development and specifically our health efforts here, focused on this problem. And one of the important things I think the report does, particularly through the data that's presented, right, and the exploration of the data and implications it's presented, is to call -- is to provide the basis for such a focused program by the United States, first and foremost.

Second, it calls upon the United States to look at the allocation of resources that Governor Daniels was talking about here. We allocate very little. And the conclusion of the report is that, given the proven approaches that we have to specific problems, that a modest increase or appropriation, allocation of resources can have a very significant impact.

Third, it is different in the low- and middle-income countries today in 2014 with respect to these outcomes than it has been for the developed countries. It's different -- different tracks, different circumstances, different infrastructures, and they're getting far worse outcomes that can be affected -- the next point is -- by specific interventions that are laid out here. And that was really something that we spent a lot of time on, which is basically, all right, what can we affect, all right?

And the three that Tom went through, with respect to low-cost drugs that are off-patent right now for hypertension, the kinds of vaccinations that we can undertake -- you know, cervical cancer situations in sub-Saharan Africa really is -- can be dramatically affected through interventions that we know work and intervention now in tobacco can have a significant impact.

Then the last point I would make is -- and it's laid out in the report with respect to what to do -- is also "do it now". This problem's going to get worse, and there are some places -- and tobacco is an example we can talk about -- where an intervention now would make a tremendous difference. Tobacco use in Africa, for example, right now is at a fairly low level. It's going to rise, and it's going to have tremendously bad impact. And an intervention now can have a tremendous effect. So those are the kinds of discussions that we had.

And the last thing -- on this question that Mitch said, which is that, you know, I've been involved in a lot of task force reports at the Council on Foreign Relations over the years. And, you know, national security officials have views that get represented in various reports. Here we really did hew, I think, to the -- to the Daniel Patrick Moynihan admonition that everybody's entitled to their opinions, but not their own facts.

And that really was an important part, I think, of the dynamic here, that we wanted to -- really, it was kind of a show-me exercise here that led us to these conclusions.

CALABRESI: Well, I think your comments have shown the specificity both of the findings and of the responses, and I think without further ado, we can then start taking some questions from the assembled audience. A couple of quick reminders for the Q&A session. Please wait for the microphone and speak directly into it. Stand. State your name and your affiliation, please. And, please, as always, keep your questions concise and to the form of a question.

Why don't we start here with the gentleman with the beard at the center table right behind you?

QUESTION: Thank you. Gentlemen, this is a terrific report coming at a very important time. My name is Jeff Meer. I'm with the Public Health Institute. And I'm the co-chair of an organization called the NCD Roundtable, which exists to build awareness and to help create new resources for the U.S. government response to NCDs. We would welcome any folks here joining our group and our effort.

But in terms of the report, the one thing that comes to mind and -- this is not going to be a surprise to those who follow NCDs regularly -- is that we've had difficulty getting traction, to say the least, with our interlocutors on the Hill, specifically. And I'm wondering if the gentlemen represented on the panel here today have any advice for those of us in the advocacy world about how we can leverage this terrific, groundbreaking report into awareness and action on Capitol Hill. Thanks very much.

CALABRESI: Governor, can you fix Congress?

(LAUGHTER)

DANIELS: Well, don't I wish? Two quick thoughts. One -- and this may not prove useful, but it's, I think, an important statement in the report -- and one day it needs to be -- we need to find a way to make it effective -- and that is, when we talk about trying to shift attention, as these decisions are made, from disease-based to outcome-based criteria, and we all know that the -- why and how human and natural it is that a lot of these decisions do get driven on a disease-specific basis. There's emotion around it and passion and, of course -- but what these data shout is that if you think about outcomes, it will pull you inexorably and quickly in the directly that your organization and our recommendations talk about.

I mean, you'll come across the stunning factoid in the report that, using the conventional measure -- disability-adjusted life years -- $44 for AIDS, $4 for malaria, $0.02 for all NCDs put together. And so if the conversation can be moved somehow further in the direction of outcomes, then I think the kind of actions that are suggested here and that you're probably advocating, become pretty hard to argue with.

CALABRESI: The appropriations process. The lady with the glasses right there, yep. No longer...

QUESTION: Sorry. Thank you. Stephanie Burgos with Oxfam. Thank you very much for a fascinating report, which I haven't yet had a chance to read, but from the presentation, my question goes to in terms of what the U.S. can do, and particularly shovel-ready issues. I noted the focus on tobacco prevention, yet we see what I would call policy incoherence in terms of U.S. -- through our trade agreements actually pushing liberalization of -- for sending -- selling cigarettes overseas, for prohibiting labeling, et cetera.

So there are a lot of things I think that could be done. We see the pressure on India and other developing countries to change their intellectual property regimes so that they don't use public health flexibilities to make medicines available at a cheaper price.

So are there things -- did the task force look at those types of things that could be done that -- to utilize -- without spending more money, but to utilize existing policy measures by making U.S. policy more coherent in some of those ways or even using the federal funds that go to research and development now to make medicines more available in the developing world? Thank you.

CALABRESI: Interagency. Tom?

DONILON: Well, but on that -- why don't we go to Tom, who is the expert in this specific trade area.

CALABRESI: OK.

BOLLYKY: Sure. For those of you who haven't read the report, when you do, you'll see the task force actually directly took home the issue of tobacco and trade. There is a recommendation in the report that the U.S. and trade negotiations moving forward should negotiate an exception that encompasses the full range of tobacco control laws, both domestically and under international law, specifically the Framework Convention on Tobacco Control.

So the report did make that recommendation, and it was unanimous, which is remarkable, given multiple trade officials on the task force and bipartisan.

In terms of medicines, there is a real problem around availability in these countries. For -- when you look at a population level, the vast majority of it, though, however, is drugs that are off-patent. They're statins. They're ACE inhibitors, beta blockers, the kinds of things -- I mean, insulin has existed since the 1920s, but isn't necessarily as widely available or as affordable as it should be in a lot of these countries.

It's a whole range of interventions like that. So in terms of what we really recommended, what can be done now, shovel-ready, these long-existing, very cheap interventions -- if you're going to invest somewhere -- seem like a better route to go.

DONILON: And it's a classic interagency problem in the United States government. It's not the province of any single agency in the U.S. government. And in my judgment and experience, I think it can only be -- it can only be run through kind of a declaration from the president and the White House that this is an important development and health priority, and to charge the national security adviser and the National Security Council to put together a coherent strategy and implement it.

There's really no other way in our government to get something done cross agency, except through that -- except through that mechanism. No single agency can take it on and do it effectively. And in this case, if I were designing it, you would design an interagency process that would pull together the trade officials, health officials, AID, State Department, and infuse a strategy into money allocation, bilateral relationships, activities in international institutions, perhaps some new initiatives.

I think particularly there's a lot -- I mentioned it very briefly at the beginning -- there's a lot here potentially in terms of bilateral cooperation with some large countries around the world who have a big interest in this, like the Chinese.

CALABRESI: So I hesitate to put you on the spot, Tom, but just so we don't pass by that too quickly, that sounds like a recommendation from Barack Obama's former national security adviser to his former boss to adopt a policy?

DONILON: That's one of the thrusts of the report. And that's the work that the task force did, again, starting out from a -- as Governor Daniels says, starting out from a position of asking ourselves -- asking ourselves some hard fundamental questions about whether this should be that kind of issue, whether it should be the kind of issue that would be a priority for our development assistance and our health issues, health efforts, and with some skepticism at the beginning, with a lot of hard work, looking at the facts, came to the conclusion that, in fact, we would make that kind of recommendation to the U.S. government.

CALABRESI: Who else? Let's see. In the -- further in the back there. Yes, no, that's you with the yellow tie. Yep.

QUESTION: Thank you. My name is Patrick Kelley. And at the Institute of Medicine, I direct the Board on Global Health. You know, chronic diseases are very different from acute diseases and demand a lot of the health system. I'm wondering, in addition to the types of interventions that you've alluded to, whether the task force addressed any time to looking at the need for strong underlying health systems to be the platform or the delivery system to deliver these interventions. If you only have the tools, but not the underlying system, it's hard to achieve the ultimate goals. I wondered if you had any insights relating to health systems versus some of the specific technical interventions.

CALABRESI: That's also been a big issue for some of the larger NGOs, Gates Foundation and so forth. Anybody want to...

DANIELS: Well, Tom will remember and say more, but, yes, we had long discussions about that. Again, you'll find under the short-term category, we were looking, really, at preventive measures, recognizing that systems aren't ready for long-term palliative or treatment in many cases. And I do remember -- and the report speaks to the fact, however -- that there are possibilities to build on the platform of those successful global initiatives that have already gone on, and we ought to -- in terms of infrastructure building, we ought to look to those opportunities to bolt on or extend the -- those systems which have been put in place to fight AIDS, for instance, and...

BOLLYKY: I agree with that. And I agree with the point you made about health systems. There's no question, in high-income countries and low-income countries alike, the long-term solution to premature death and disability from NCDs is functional health systems, it's better urban design, it's more sensible agricultural policies. You can really go across the gamut.

What's unusual about low- and middle-income countries is we're asking them -- or they're being forced to do that on a much shorter timeframe than we have with far fewer resources. And given that, I think one of the reasons why it's been hard to make progress on NCDs personally is that the answer can't be to start with a whole-of-governments solution to this problem. There need to be specific things that you can do to start addressing these countries' needs now and afford them the time to be able to respond to the longer-term concerns that this emerging epidemic raises. And that's what we focused on in the report.

But we acknowledge that any long-term -- as you put it, Patrick -- the ultimate goal in this solution can only be reached through having functional health systems. The question is, what we wanted to put in this report is that you don't have to wait for that to occur. There's lots that can be done now.

CALABRESI: Yes, Anya?

QUESTION: Thank you. Anya Schmemann, American University. The current communicable global health crisis is Ebola, which has thrown a spotlight on the lack of infrastructure and the need for health reform in the effected countries. It's also highlighted the role of the international community. I wonder what other lessons you can draw from the Ebola crisis that can be applied to NCDs?

CALABRESI: Who wants to tackle the...

DONILON: Well, I'll say a couple things on it. I'm not an expert in this area, but a couple things. One is, this effort is not in competition, obviously, with an effort to deal with the Ebola crisis. And I think it's the first point. It's a crisis that the administration -- the United States is seeking additional resources for and is working with the international community to address and needs to, number one.

That doesn't take away from the fact that this NCD threat is the most significant long-term threat to low- and middle-income countries. And, third, I guess my observation would be that a number of the challenges you have with respect to Ebola, as you set forth, exists with respect to the NCDs, and they are this infrastructure, these other infrastructure issues.

In response to the prior question, we really did -- we focused on that, but we also focused here on -- as Tom said -- trying to get things done now and building on existing U.S. and international global health platforms. But those are the kinds of -- those are a couple of the thoughts that I come away from in thinking about this -- putting this task force report together during the course of the Ebola crisis.

I don't know, Tom, if you have other...

BOLLYKY: The only thing I would throw out, I mean, is -- well, first, to acknowledge, Anya was the first task force director who started this project, and I also want to acknowledge her successor, Chris Tuttle, because they both have -- did terrific work on this.

But the drivers behind the Ebola crisis, what made this different from the twenty-five previous outbreaks of Ebola is it was the first real urban outbreak of this disease. What I think that highlights is that there's unprecedented rates of urbanization going on in these countries. It isn't in the mega-cities that you think. It's by and large cities of a million people or fewer. There's limited public health infrastructure in those settings, and you have, as we discussed before, in many areas, and particularly in West Africa, very rudimentary health systems.

Those are the same drivers behind a lot of this noncommunicable disease issues. And I think it's incumbent on us -- the world's attention is focused on Ebola now. I think the president has asked for something in the area of -- somebody mentioned in the back room there $7 billion at this point. It's incumbent to spend that money in a way that is more broadly applicable, in my view, than just Ebola. There's lots that needs to be done in these countries.

CALABRESI: Terrific. Yes, right here, yes. Oh, nope, right behind you there. Thanks.

QUESTION: Thank you very much. I'm Paul Isenman. I'm a consultant on global health and education programs, working with Results for Development Institute. Coming back to the tobacco issue, which has come up, I'd like to congratulate the whole team. I have read that section, and it's really great, and I'd commend it to everyone. And I don't want to put words into your mouths, but given what you've said already about the importance of tobacco control, and given the tobacco -- that raising tobacco taxes, I think, is generally agreed to be one of the very most cost-effective things that can be done in all of public health, not just the NCDs, and that it raises money for health systems in general, would you agree that the U.S. government, if there were to be a task force of the sort that you recommended or not, should in all of its efforts, including its aid, U.S. aid, as well as trade, give very, very high priority to getting countries to raise tobacco taxes to save lives and to raise money for other programs?

And I mention that because I think where it ranks now, as far as I can make out, on the priority list is, you know, somewhere way down there, when it ought to be way up. So do you agree or not?

CALABRESI: Taxes on tobacco, Governor?

DANIELS: Well, I doubled -- was party to doubling tobacco taxes. And what the gentleman says is true. It's pretty straightforward economics and works. And you can put the money, yes, to -- best done, best sold, I think, if you plan to devote the money, as we did in our small instance, to important health promotional -- in our case, the coverage of uninsured citizens.

So, yeah, and I think the report is about as explicit as it needs to be and encouraging in exactly the direction you're talking about.

DONILON: And to provide -- and to provide advice and assistance from the United States with respect to our experience in that area, technical advice and assistance in that area, and to give them the ability to move in that -- give other countries the ability to move in that direction, with the benefit of our experience.

CALABRESI: Terrific. Let's see. Yes?

QUESTION: Cameron Massey with the Livestrong Foundation. The report noted the challenges with trying to assess what exactly the U.S. government is spending on NCDs. And I'm just hoping that you can clarify for me whether there is a specific recommendation for an additional investment by the U.S. government, and if so, what is that amount? And if not, why did the report fall short of recommending a specific amount?

CALABRESI: Good question.

QUESTION: Thank you.

CALABRESI: Is there a specific amount?

DANIELS: No.

BOLLYKY: There is, of a sort. What we did in the report is we do acknowledge -- and we did as thorough of a look at that you can. In terms of what the U.S. currently spends, when you look at the report, you'll see a very detailed cataloguing of all the U.S.'s programs in this area, so we tried to uncover as much as we could.

What we uncovered from that is, $10 million out of a global health budget of more than $8 billion. That's what the report shows. We indicated in the report is we -- for each of -- particularly the shovel-ready recommendations, we make recommendations about -- or we show what the cost-effectiveness of those recommendations might be, so we do that.

In terms of how much it's going to actually cost, a lot of that depends on how well it can leverage existing U.S. systems and whether that adds money to try to integrate it in or makes it more affordable. What we did say in the report, is given what we've shown on cost-effectiveness, if the U.S. was just to look at some of the other areas where the U.S. has global health priorities that are priorities, but not something necessarily that we spend a lot of money on -- let's say, tuberculosis.

Tuberculosis in 2013, I think, received $236 million. And what we say in the report is that if you were to spend that much, that would go a long way in implementing a lot of the solutions that we put in the report. It would also be a twenty-three-fold increase than what we spend now. So that's -- we do mention it in the report, but Mitch is quite right. We did not do a detailed cost analysis of what -- if the U.S. implemented it, what it would cost.

DANIELS: Yeah, I mean, the way I recall, I mean, we consciously avoided picking some number, because you and everyone else would have immediately zoomed in on that and overlooked all the more fundamental points we were trying to make, so I think it perfectly suffices to say, once again, that this tiny trifle we're spending now cannot be the right answer. Whatever the right answer is, barely 0.1 percent of 0.2 percent of the federal budget cannot be correct.

CALABRESI: Perfect. Yes? Yes, that's right, there we go.

QUESTION: Thank you very much. My name is Lisa Carty, and I'm from the Joint United Nations Program on HIV-AIDS, and for the past three years, I've been very involved with one of the initiatives you mention in the report, which is the pink ribbon/red ribbon initiative, which works to build off some of the U.S. government's funded platforms to work on HIV-AIDS to bring in cervical cancer screening in low-income countries.

And we've seen many of the things you've described. You know, we've seen deficits in human resources, deficits in innovation to sort of get services to people. We've seen some deficits in leadership and commitment in the countries to actually work on these questions.

My question is, you've mentioned India, you've mentioned China, possibly Brazil as countries where there could be a different kind of engagement to address some of these problems. And I'm wondering if you could just talk a little bit more about how you would see that engagement unfold -- operationally, strategically? What's the entre point? And what do you think the best way to pursue it is?

CALABRESI: Excellent question. You want -- Tom, do you have...

BOLLYKY: Sure. I mean, one of the things we mentioned in the report is we conduct -- Tom, being deeply involved in these in his previous position -- we conduct regular dialogues with these countries. It's always -- I can say this as a former trade official -- it's always a challenge to find ones where you're not just there to give them a hard time, that you're doing something positive and cooperatively. This certainly provides a strong opportunity to do that. These are shared challenges.

And in terms of engaging on this -- and particularly the areas where we haven't necessarily made as much progress as we would like -- we mentioned the longer-term categories in this report about lower-cost chronic care or some of these nutritional issues or other issues. Those might provide good avenues for that.

In terms of looking at the shorter-term possibilities, we really looked at the possibility of trying to leverage existing U.S. global health infrastructure. Again, we did a very detailed analysis. For those of you who haven't seen the interactive online, I can recommend it to you. We did forty-nine country case studies of what the burden is in each of the countries that received more than $5 million per year from the U.S.

We talked about some of the infrastructure of the pilots that have gone on and the possibility for doing that. We have -- we were fortunate to have on the task force Eric Goosby, who -- for those of you who don't know -- was until recently the head of the Office of the Global AIDS Coordinator, and he was very passionate on this topic of leveraging that infrastructure.

DONILON: Lisa, I think the -- three or four different levels. You need to infuse the development assistance program between the United States and nations with this as a priority or as an affirmative element. So, for example, you know, we have substantial bilateral assistance efforts in places like Afghanistan, Pakistan, and other places in the world, less in Pakistan now, and to make this a priority in that -- in that assistance mix where we have leverage frankly, of providing assistance to countries in need.

Second would be to use U.S. leadership to make it a priority for international organizations, international health organizations, where we are typically a leader and provide typically a lot of the resources.

And, third, and I think where there's a real opportunity, is in the bilateral strategic dialogues that we have with large nations around the world, like India and China and Brazil, and to bring it formally into those structures as a -- as a priority, as Tom said, a priority where it's a win-win and something that can be done jointly and something, by the way, that we in cooperation with countries like the ones we're talking about here could work around the world, because these countries also -- like China in particular -- have programs that they work around -- that they work around the world, as well.

So I think it's going to -- got several dimensions to it, and it's -- I think that the short answer is it's making this an affirmative element in each of those channels.

CALABRESI: Let me just follow up a little bit on that. The existing infrastructure, international infrastructure for dealing with health issues -- friend or foe in this? And what is the role of NGOs, WHO, other international organizations in trying to get this coordination going?

BOLLYKY: So in terms of the international institutions, WHO and, to a lesser extent, but a significant extent, the United Nations, have spent the last decade trying to generate traction on these issues. So from the intergovernmental institution standpoint, there is -- there's buy-in.

I think the big challenge has been where the resources to -- are going to come from on this issue. And there aren't a lot of foundations that have been in the space. I want to acknowledge one, because they also supported this task force, which was the Bloomberg Foundation. They've done a lot, particularly on tobacco, the Gates Foundation, to a lesser extent, but a significant extent on tobacco and cervical cancer. But there really isn't a lot from that space.

And I think one of the things we wanted to make clear in this report is the same reasons we ultimately invest -- most of what we invest in global health isn't a direct threat to U.S. citizens. Malaria in a low-income country is not going to mean malaria in the U.S. if we didn't invest in it. Most of the things we invest in are not direct threats. We invest in them because they are debilitating to those countries and to their populations. They're driven by poverty, and they're preventable. All the same reasons apply in this instance.

One of the great -- one of the great opportunities, though, is that we already have to some degree in many of these cases interventions that can be adapted, hopefully for fairly cheap.

DONILON: Yeah, the idea, of course, is that the task force is to -- is to make this happen, right, is to provide kind of a broad-based, supported, fact-driven presentation on the challenge. Massimo, as you said at the beginning, to kind of shake the lens. Here is -- you know, what you might think is the most important health threat isn't, doesn't mean the other projects are not important that have been very successful to a large extent, but there's another challenge here that needs attention, and that's the -- that's one of the principal purposes of a task force report like this.

But the second element of it will be, as you mentioned earlier, will be the United States making a priority for its interactions with these international organizations.

CALABRESI: Perfect. Right here on the front table.

QUESTION: Well, thank you very much. Anselm Hennis, Pan-American Health Organization. First of all, let me congratulate the task force for this monumental piece of work here, which I hope will catalyze the way forward for noncommunicable diseases.

Now, within the Pan-American Health Organization, we have had a resolution, which has been agreed by member states, on universal health coverage and universal access, which obviously encompasses noncommunicable diseases.

My question to you, as a committee, how do you see the way forward for the incorporation of NCDs under the aegis of universal health coverage, universal access? It is, after all, chronic diseases.

CALABRESI: Health care coverage in developing countries and the best approach, universal or otherwise?

BOLLYKY: Yeah, I mean, to some degree -- it's a great question -- but to some degree, it's very similar to Patrick's question, which is, there's no question -- in these countries, having competent health systems is the only way to make a long-term progress on these issues.

We focused in this report on just the noncommunicable disease issue and also specifically on what the role of collective action might be, meaning international initiatives ideally led by the U.S., but working with partners, as well, in fostering that process. So that's what we came up in the recommendations.

DANIELS: I mean,one answer that's just important, huge, cosmic question, but way outside the scope of our assignment, but within our report -- and just to state what I guess is obvious anyway -- a major reason this ought to engage all our attention is because it threatens the economic growth of these countries in a very real way.

You know, a lot of developed countries, it's been observed, have the problem with their low birth rates and so forth. They've gotten old before they've gotten wealthy. And these countries are getting sick before they've gotten wealthy. And the incidence, as the data kept showing us, is outrunning the per capita income, for instance, it increases.

And so it's the noblest aspiration of all, universal access to affordable health care, but you're never going to have it in any society if you don't have the economic, you know, wealth and, in these cases, a lot of growth to support it.

And so I think -- the way I look at it, the horse here is to begin getting on top of these problems so these countries can grow to the level that we all dream that they will reach.

CALABRESI: Terrific. Yes, in the sweater here, thank you.

QUESTION: Hi, Nancy Roman, formerly with the United Nations, working on hunger and health, and now with the region's largest hunger organization here. And thank you very much for the conversation and the report. One of the things sometimes at the Council I struggle with, the division between the foreign policy and the domestic policy. The budget's configured that way. But this is one of those times I think a merged conversation would benefit us.

We're serving 530,000 people here, low-income, hungry people. Of those, 49 percent have heart disease and 23 percent have diabetes or are living with a diabetic, right here in the greater Washington area, never mind the rest of the country.

And as I've been listening to the conversation and coming from the U.N. and caring so much about the issues elsewhere, two questions. One, just your thoughts on dividing the low-income countries, you know, low and emerging countries from the other countries who struggle with these diseases, as well, for reasons other than budgetary channels in Congress.

And then the second question I had is just, how much did you all think about nutrition? You know, diabetes and heart disease are diet-related diseases, and the biggest thing you can do is eat well and communicate that information, which we're very focused on. Thank you.

CALABRESI: So why divide the low-income countries, middle-income countries from the rest of the world?

BOLLYKY: So most -- really, every initiative I can think of on noncommunicable diseases has dealt with them globally. The U.N.'s high-level meeting on noncommunicable diseases dealt with all these diseases globally.

The reason why we wanted to separate it out in this particular instance is the one I mentioned at the outset, that when you look at -- certainly at a population level, which doesn't mean there aren't poor people in this country having these issues, as well, the drivers between what's driving this rapid increase in low- and middle-income countries and what's driving the persistence of these problems in high-income countries like the U.S., are different.

And if you deal with them in combination, you have a difficulty coming around a set of coherent policies. And I think what you end up with is whole of society's approach, we need to remake everything before we can do anything. And I think noncommunicable diseases have been in that box for a long time. So we wanted to be really, really focused about it.

On nutrition, it played a -- as you'll see when you see the report, we do talk about nutrition. It is a big issue in these countries. According to our good friends and colleagues at the Institute of Health Metrics and Evaluation, the leading health risk in low- and middle-income countries is diet.

The thing about that, though, is it's not salty, fatty foods. It's lack of diet diversity. It's...

CALABRESI: I'm sorry, it's lack of what?

BOLLYKY: Lack of diet diversity. Things are disappearing from diets. So more and more people are existing on fewer and fewer things. The accessibility of whether it be fruits or vegetables or other staples that have healthful impacts have really disappeared in these settings. And that's just yet another indication of why dealing with these things globally is really hard, because the problems are different.

DONILON: Yeah, and we discussed -- we've certainly discussed nutrition during the course of this, the discussions, and I think -- I don't have the report in front of me here -- I think Dan...

DANIELS: Dan wrote additional...

DONILON: ... wrote a...

(LAUGHTER)

DANIELS: ... views on that subject, which was...

CALABRESI: Terrific.

DANIELS: ... very helpful.

CALABRESI: We have time for one quick last question. The gentleman at the table there. "The gentleman at the table" is not very specific. There, yes.

QUESTION: Thank you for the report. Paul Holmes, formerly with USAID, now with Development Finance International. I'm wondering if you could just comment on a point that I took away from the report that has not been emphasized today, and that is that the work on NCDs is complementary to, rather than competitive with, existing health priorities. In other words, by investing in NCDs, we're actually accelerating our work on our existing priorities and complementing that -- that work. Thank you.

DONILON: The point we make in the -- the point we make in the report pretty clearly...

BOLLYKY: Yeah, I mean, the point we make in the report...

DONILON: ... on the same population, same...

(LAUGHTER)

BOLLYKY: Same population, same -- same problems. That's one of the reasons why -- I mean, so much of what we do in global health is supply-driven, instead of demand-driven. I was at a meeting the -- a few months ago on the best buys in global health, and somebody had asked the U.S. official -- I won't specify the agency or the person -- about tobacco and some other things. And that person had to say we're interested in best buys for malaria and HIV.

And one of the things we point out in the report is that this should be demand-driven by what the population in the countries that we're investing in have and the problems that are driving premature mortality and morbidity in young people, in young poor people.

We didn't see them as competitive. The report doesn't make a recommendation about moving money away from other sources. We do talk about shifting to an outcome approach. That said, as Mitch recognized before, there's enormous disparities. We're a very long way away from making these a priority.

CALABRESI: Terrific. Thank you very much for excellent questions. And thank the panelists and thank the Council for the report.