Il contrasto alla cronicità

Milioni di persone al mondo ammalano e muoiono prematuramente a causa di 4 NCDs (non-communicable diseases: malattie cardiovascolari, tumori, malattie respiratorie croniche, diabete) che sono in larga misura prevenibili, riducendo 4 principali fattori di rischio: uso di tabacco*, uso pericoloso di alcolici, dieta non salutare, inattività fisica.
Il carico di NCD continua a crescere specie nei Paesi meno avanzati, giacchè la povertà peggiora l’impatto delle NCD. In molti Paesi l’obesità di adulti e bambini è in aumento e con essa le malattie croniche che ne derivano. La prevalenza del diabete è in crescita da 40 anni e in alcuni Paesi come gli USA è triplicata. Si stima che nel mondo esistano 415-425 milioni di diabetici e che questo numero raggiunga 700 milioni nel 2025. Frenare questa crescita è urgente e indispensabile per evitare che i Servizi Sanitari diventino insostenibili. Il numero di morti premature è cresciuto tra il 2000 e il 2015, ma le mortalità da patologie cardiovascolare e respiratoria sono diminuite di circa il 17%. I Governi devono assumersi la responsabilità di intervenire per ridurre la dieta non salutare (ricca di zuccheri, grassi e sodio) e l’inattività.
Anche l’inquinamento dell’aria, sia fuori che dentro casa, deve essere affrontato perché comporta NCD: è il traffico veicolare nelle città una delle cause principali.
Anche la prevenzione e il trattamento delle malattie mentali è un obiettivo urgente, specie la depressione che affligge 300 milioni di persone nel mondo, con circa 800.000 suicidi ogni anno. Più in generale le persone con malattie mentali vivono 10-20 anni meno delle persone normali.
Gli Stati peraltro hanno a disposizione strumenti e Linee Guida per affrontare la situazione e migliorarla, specie quelle prodotte dal WHO e dalle Nazioni Unite con l’obiettivo di ridurre del 25% la mortalità prematura da NCD entro il 2025 (25×25). Questo obiettivo è ben lontano dall’essere raggiunto e i progressi nel mondo sono stati scarsi. Nel 2017 molti Stati hanno concordato sull’obiettivo di ridurre del 30% la mortalità prematura entro il 2030 tramite la prevenzione e la cura delle NCD, specie quelle provocate dall’uso di tabacco, alcolici e dieta non salutare. Nessuno ignora che le forze che contrastano questi obiettivi sono numerose e forti (DeMaio A, Marshall R. Sacral lobbyng: call to arms for public health. Lancet 391, 1558-59, 2018); per questo la società civile deve mobilitarsi per sostenere e stimolare i Governi ad agire con determinazione.
La Commissione Indipendente del WHO ha pubblicato nel 2018 delle Raccomandazioni ai Governi che possono essere utili per mettere in atto un contrasto efficace alla cronicità, se applicate. A queste va poi aggiunta la Raccomandazione di utilizzare senza esitazione lo strumento fiscale (tasse) per scoraggiare i consumi di tabacco, alcol e zuccheri [Sugar, Tobacco and Alcohol Taxes (STAX) Group. Sugar, tobacco and alcohol taxes to achieve the SDGs. Lancet 391, 2400-1, 2018]. Qui di seguito vengono riportate le Raccomandazioni ai Governi (Nishtar S et al. Time to deliver: report of the WHO Independent High-Level Commission on NCDs. Lancet 392, 245-52, 2018):

RECOMMENDATIONS

Start from the top: political leadership and responsibility, from capitals to villages
RECOMMENDATION 1: (a) Heads of State and government, not Ministers of Health only, should oversee the process of creating ownership at national level of NCDs and mental health. (b) Political leaders at all levels, including the subnational level, for example, city mayors, should take responsibility for comprehensive local actions, together with the health sector, that can advance action against NCDs and mental disorders.

Priorities and scale up
RECOMMENDATION 2: Governments should identify and implement a specific set of priorities within the overall NCD and mental health agenda, based on public health needs.

Embed and expand: NCDs within health systems and UHC
RECOMMENDATION 3: Governments should reorient health systems to include health promotion and the prevention and control of NCDs and mental health services in their UHC policies and plans, according to national contexts and needs.
(a) Governments should ensure that the national UHC public benefit package includes NCD and mental health services, including health promotion and prevention and priority health care interventions as well as access to essential medicines and technologies.
(b) Primary health services should be strengthened to ensure equitable coverage, including essential public health functions, with an adequate and well-equipped multi-disciplinary health workforce, especially including community health workers and nurses.
(c) Synergies should be identified in existing chronic-care platforms, such as HIV and TB, to jumpstart NCD and mental health services.

Collaborate and regulate
RECOMMENDATION 4: Governments should increase effective regulation, appropriate engagement with the private sector, academia, civil society, and communities, building on a whole-of-society approach to NCDs, and share experiences and challenges, including policy models that work.
Governments
(a) Governments must take the lead in creating health-protecting environments through robust laws, where and when necessary, and through dialogue, where appropriate, based on the “health is the priority” principle, including clear objectives, transparency, and agreed targets. Dialogue must not, however, replace regulation in cases where regulation is the most or the only effective measure. Any dialogue platform should include transparency and a mechanism for accountability and evaluation as well as a timeframe.

Private sector
(b) Governments should be encouraged to engage constructively with the private sector-with the exception of the tobacco industry and with due attention to the management of commercial and other vested interests, while protecting against any undue influence, to seek ways to strengthen commitments and contributions to achieving public health goals, in accordance with the mandate of the SDGs.
(c) Taking into account and managing possible commercial and other vested interests, in order to contribute to accelerated progress towards SDG target 3.4, governments should work with: food and non-alcoholic beverage companies in areas such as reformulation, labeling, and regulating marketing; the leisure and sports industries to promote physical activity; the transportation industry to ensure safe, clean, and sustainable mobility; the pharmaceutical industry and vaccine manufacturers to ensure access to affordable, quality-assured essential medicines and vaccines; and with technology companies to harness emerging technologies for NCD action. Governments could also encourage economic operators in the area of alcohol production and trade to consider ways in which they could contribute to reducing the harmful use of alcohol in their core areas, as appropriate, depending on national, religious, and cultural contexts.
(d) Governments should give priority to restricting the marketing of unhealthy products (those containing excessive amounts of sugars, sodium, saturated fats and trans fats) to children. WHO should explore the possibility of establishing an international code of conduct on this issue, along with an accountability mechanism, while acknowledging the need for partnerships based on alignment of interests.
(e) Both fiscal incentives and disincentives should be considered to encourage healthy lifestyles by promoting the consumption of healthy products and by decreasing the marketing, availability, and consumption of unhealthy products.

Civil society and the public
(f) Governments should ensure the meaningful engagement and participation of civil society and people living with NCDs and mental disorders, including, where appropriate, by strengthening civil society and alliances, particularly in low-income and middle-income countries. Governments should work with civil society to raise awareness, increase advocacy, deliver services, and monitor progress. Beyond civil society, multi-sectoral mechanisms, such as national NCDs commissions and equivalents of the Global Coordination Mechanism, can be employed to ensure wide consultation.
(g) People with mental health conditions and civil society must be engaged to effectively end discrimination and human rights violations. They should also be involved in the planning of mental health services.
(h) Governments should increase the empowerment of individuals to take action by actively promoting health literacy, including in formal education curricula, and targeted information and communication campaigns. This could include convening marketing experts and behavioural economists to develop public health campaigns designed to educate different populations on how best to prevent and mitigate the risk factors and harms of NCDs.

Supporting role of WHO
(i) WHO should support governments’ efforts to engage with the private sector for the prevention and control of NCDs, including any necessary regulatory action, taking into consideration the rationale, principles, benefits and risks, as well as the management of conflicts of interest in such engagement.

Finance
RECOMMENDATION 5: Governments and the international community should develop a new economic paradigm for funding action on NCDs and mental health.
(a) National governments should:
– Develop and implement a new economic paradigm for actions against NCDs, based on evidence that effective measures are investments in human capital and economic growth.
– Increase the percentage of national budgets allocated to health, health promotion, and essential public health functions, and within health, to NCDs and mental health.
– Implement fiscal measures, including raising taxes on tobacco and alcohol, and consider evidence-based fiscal measures for other unhealthy products.
– With the support of tools developed by WHO, conduct health-impact assessments and, where possible, full-cost accounting, which factors in the true cost to societies of policies that have a bearing on NCDs.
(b) The international community should:
– Increase financing and lending for the prevention and management of NCDs through bilateral and multilateral channels.
– Explore a number of mechanisms to increase financing for NCD action, which could include: the establishment of a Global Solidarity Tobacco and Alcohol Contribution as a voluntary innovative financing mechanism to be used by Member States for the prevention and treatment of NCDs: and consider the establishment of a multi-donor fund, to catalyse financing for the development of national NCDs and mental health responses and policy coherence at country level.
– Integrate NCDs into human-capital and human development indices.
– Convene a health forum for investors to support action against NCDs.
(c) WHO should prioritise NCDs and mental health. This requires that Member States consider increasing or reallocating their contributions to the Organization so that WHO can meet the demand for country support. Support for addressing NCDs is the leading request from countries, but the Organization’s budget has been reduced in the current biennium owing to lack of financing from donors.

Act for accountability
RECOMMENDATION 6: Governments should strengthen accountability to their citizens for action on NCDs.
(a) Governments should create or strengthen national accountability mechanisms, taking into account the global NCD accountability mechanism and health-impact assessments.
(b) WHO should simplify the existing NCD accountability mechanism and establish clear tracking and accountability for the highest impact programmes that can lead to achievement of SDG target 3.4, including a harmonized Countdown 2030 for NCDs and mental health.

* Il mercato mondiale del tabacco (esclusa la Cina) si stima in US$ 760 miliardi, generato dal consumo di 5.500 miliardi di sigarette all’anno. Whitington P. Taking to tobacco. Lancet 392, 206-7, 2018.
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