Grand challenges in chronic non-communicable diseases

The top 20 policy and research priorities for conditions such as diabetes, stroke and heart disease.

Chronic non-communicable diseases (CNCDs) are reaching epidemic proportions worldwide^1,2,3. These diseases — which include cardiovascular conditions (mainly heart disease and stroke), some cancers, chronic respiratory conditions and type 2 diabetes — affect people of all ages, nationalities and classes.

The conditions cause the greatest global share of death and disability, accounting for around 60% of all deaths worldwide. Some 80% of chronic-disease deaths occur in low- and middle-income countries. They account for 44% of premature deaths worldwide. The number of deaths from these diseases is double the number of deaths that result from a combination of infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies.

Over the coming decades the burden from CNCDs is projected to rise particularly fast in the developing world. Without concerted action some 388 million people worldwide will die of one or more CNCDs in the next 10 years. With concerted action, we can avert at least 36 million premature deaths by 2015. Some 17 million of these prevented deaths would be among people under the age of 70 (ref. 2).

CNCDs have a huge negative economic impact⁴. In the next 10 years, China, India and the United Kingdom are projected to lose $558 billion, $237 billion and $33 billion, respectively, in national income as a result of heart disease, stroke and diabetes, partly as a result of reduced economic productivity².

Poor diet and smoking are two factors that contribute to the millions of preventable deaths that occur each year. Credit: R. CANDIA/AP

Several factors are implicated in this increasing burden, including longer average lifespan, tobacco use, decreasing physical activity, and increasing consumption of unhealthy foods. Fortunately, CNCDs are largely preventable⁵. Up to 80% of premature deaths from heart disease, stroke and diabetes can be averted with known behavioural and pharmaceutical interventions².

Yet the prevention of disability and death from CNCDs gets scant attention worldwide. In sub-Saharan Africa it is understandable that governments, donors and research-funding agencies have channelled most resources into infectious diseases: 5.9% of adults between the ages of 15 and 49 are HIV positive⁶ and malaria alone kills a million children under the age of five each year⁷. In most richer countries the focus of biomedical research on CNCDs has been on treatment rather than prevention.

With concerted action, we can avert at least 36 million premature deaths by 2015.

A crucial aspect of establishing programmes for disease control globally is to identify priorities. To galvanize the health, science and public-policy communities into action on this epidemic, we present here an inventory of 20 grand challenges, grouped under 6 goals, arrived at through a global, structured consensus process.

Two previous 'grand challenge' exercises — the historical one by David Hilbert⁸ in mathematics more than a century ago, and the 2003 Grand Challenges in Global Health initiative spearheaded by the Bill & Melinda Gates Foundation⁹ — showed that the approach focuses significant new attention on an area of study, energizes communities to rise to meet the challenges, and brings new talent to the field. Although there has been interest in CNCDs among governments in developed countries, research-funding agencies and others¹⁰, this has been incremental and rare in developing nations.

The Grand Challenges in CNCDs we describe here are intended to reduce the global epidemic of these diseases by making the case for worldwide debate, support and funding, and by guiding policy and research in an evidence-based manner.

The Delphi method

To develop the grand challenges, we used the Delphi method — the structured, sequential questioning of a panel, with controlled feedback^11,12,13,14 — to distil knowledge and build reliable consensus among 155 geographically and culturally diverse stakeholders, from 50 countries. We used the following definitions.

A 'grand challenge' was defined as a specific critical barrier that if removed would help to solve an important health problem. The intervention(s) it could lead to might be innovative and, if successfully implemented, would have a high likelihood of impact and feasibility.

'Chronic non-communicable diseases' were defined as diseases or conditions that occur in, or are known to affect, individuals over an extensive period of time and for which there are no known causative agents that are transmitted from one affected individual to another. For the purpose of this study the major focus was on cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and certain cancers. Commonly known risk factors for these include lack of exercise, improper diet and smoking. Note that we excluded mental health and chronic neurological conditions because their risk factors and interventions are so different².

We asked the panel: “What do you think are the grand challenges in chronic non-communicable diseases?” The first of the three Delphi rounds elicited 1,854 ideas, many of which overlapped. We distilled these into 109 from which the panel selected, ranked and commented on its top 30. These comments and rankings structured the final round: panellists were asked either to accept the list or to re-rank the choices. see table 1

Table 1 Grand challenges in chronic non-communicable diseases

The executive committee and scientific board refined the wording and presentation of the panel's conclusions into the Table published on the previous page (the order does not denote relative importance). Also summarized in the Table are key research needs that the committee and board matched to the goals.

Blueprint for change

The integration of science, technology, policy and social sciences makes the Grand Challenges in CNCDs a particularly comprehensive — if demanding — blueprint for change. For each group of grand challenges we suggest the research now needed.

Many of the grand challenges relate primarily to policy interventions, such as reform of professional training and modification of health systems. These, too, will need evaluation during implementation and ideally should have an evidence base that links research to policy. For example we know about preventing heart attacks and strokes associated with smoking or high blood pressure, but how should we best put these ideas into practice, especially in low-resource settings or on a large scale?

It is not possible to provide a complete list of the research activities that will be required for these grand challenges to be solved systematically, but here we highlight the important ones. Interdisciplinary research will be needed, for example, to explore the interactions of behaviour, environment and genetics in framing risks and determining outcomes. Such research will also need to focus on equity, and on the effects of gender and culture on risk, the effectiveness of interventions and access to health care. Ethical, social, cultural and sustainability issues must be addressed before emerging interventions and technologies can be taken up by communities and incorporated into public-health and health-care systems^15,16. Data and research repositories will also be essential, and standardization, where possible, will allow international comparisons and help global partnerships.

Although these challenges are applicable to all countries, different nations should identify local priorities from among those identified here for immediate attention, depending on resources and disease patterns.

Next steps

Addressing the challenges identified here requires the participation of governments, the World Health Organization, the World Bank, regional development banks, foundations, research-funding agencies, donor agencies and others. The business community and civil society organizations will also be crucial partners. A global governance mechanism to coordinate this work across different sectors will be important to prevent dissipation or duplication of effort.

With this publication, the Grand Challenges Global Partnership is being established with a secretariat in the Oxford Health Alliance (OxHA). It will be funded for the first 5 years by members of OxHA (http://www.oxha.org). The partnership is intended primarily as a coordinating body for research-funding organizations and to harmonize efforts among other relevant initiatives^10,17. The founding partners, OxHA, the UK Medical Research Council, the Canadian Institutes of Health Research, the Indian Council of Medical Research and the US National Institutes of Health intend to expand the partnership, forge collaborative research opportunities, and monitor progress towards meeting these challenges. An advocacy programme will also be developed, to encourage adoption of the challenges and goals.

With the Grand Challenges in Global Health (http://www.gcgh.org) initiative there was an upfront commitment of US$200 million (later increased to $450 million) in research funding. By contrast, the Grand Challenges in CNCDs are not linked directly to a funding programme. These problems require initial financing, a long-term commitment and a coordinated effort between multiple funding agencies around a set of clear priorities. Providing such priorities is the major goal of this grand-challenge exercise. The growing interest in this area of research now being registered by governments and funding agencies suggests that substantial resources may be available in the future.

In the first instance, the main function of the Grand Challenges Global Partnership will be monitoring and reporting. It will provide cross-referencing between agencies to ensure efforts are complementary and that major objectives are not overlooked. We will therefore prepare for the research-funding agencies and foundations an annual progress report, beginning a year from now.

Chronic non-communicable diseases constitute the major burdens of illness and disability in almost all countries of the world. They must urgently receive more resources, research and attention, as mapped out in these grand challenges. Inaction is costing millions of premature deaths throughout the world.